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THE 
CASE HISTORY SERIES 



CASE HISTORIES IN MEDICINE 

BY 

Richard C. Cabot, M.D. 

Third edition, revised and enlarged 



DISEASESOF CHILDREN 

BY 

John Lovett Morse, M.D. 

Third edition, revised and enlarged 
Presented in two hundred Case Histories 



ONE HUNDRED SURGICAL PROBLEMS 

BY 

James G. Mumford, M.D. 

Second Printing 



CASE HISTORIES IN NEUROLOGY 

BY 

E. W. Taylor, M.D. 

Second Printing 



CASE HISTORIES IN OBSTETRICS 

BY 

Robert L. DeNormandie, M.D. 

Second Edition 



DISEASES OF WOMEN 

BY 

Charles M. Green, M.D. 

Second Edition 
Presented in one hundred and seventy-three Case Histories 



NEUROSYPHILIS 

MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT 
Presented in one hundred and thirty-seven Case Histories 

BY 

E. E. Southard, M.D., Sc.D. 

AND 

H. C. Solomon, M.D. 

Being Monograph Number Two of the Psychopathic Department of the Boston State Hospital, Massa- 
chusetts. (Monograph Number One was A Point Scale for Measuring Mental Ability by Robert M. 
Yerkes, James W. Bridges and Rose S. Hardwick. Published by Warwick and York. Baltimore 1915) 



SHELL SHOCK and other NEUROPSYCHIATRY PROBLEMS 

Printed in five hundred and eighty-nine Case Histories 

BY 

E. E. Southard, M.D., Sc.D. 

Being Monograph Number Three of the Psychopathic Department of the Boston State Hospital, 

Massachusetts 





HORSLEY, 1857-I916 




DEJERINE, 1849-1917 VAN GEHUCHTEN, 1861-1914 

IN MEMORIAM 



SHELL-SHOCK < 

AND OTHER 

NEUROPSYCHIATRY PROBLEMS 

PRESENTED IN FIVE HUNDRED AND EIGHTY- 
NINE CASE HISTORIES 

FROM THE 

WAR LITERATURE, 1914-1918 



BY 

E. E. SOUTHARD, M.D., ScD. 

Director (1917-1918), U. S. Army Neuropsychiatry Training School (Boston Unit); 
Late Major, Chemical Warfare Service, U. S. Army; Billiard Professor «of Neuro- 
pathology, Harvard Medical School; Director, Massachusetts State Psychi- 
atric Institute (of the Massachusetts Commission on Mental Diseases) ; 
Late President, American Medico-Psychological Association 



WITH A BIBLIOGRAPHY BY 

NORMAN FENTON, S.B., A.M. 

Sergeant Medical Corps, U. S. Army (Assistant in Psychology to the Medical Director, 

Base Hospital 117 A. E. F.); late interne in Psychology, Psychopathic Department, 

Boston State Hospital; Assistant in Reconstruction, National Committee for 

Mental Hygiene 



AND AN INTRODUCTION BY 

CHARLES K. MILLS, M.D., L.L.D. 

Emeritus Professor of Neurology, University of Pennsylvania 



BY VOTE OF THE TRUSTEES OF THE BOSTON STATE HOSPITAL 

MONOGRAPH NUMBER THREE 

OF THE 

PSYCHOPATHIC DEPARTMENT 



BOSTON 

W. M. LEONARD, PUBLISHER 
1919 



"RC36J 
.Sid 



COPYRIGHT, 1919, BY 
W. M. LEONARD 



-FEB -21920 



©CI.A561684 

/Ho J 



Or 



Or 

/TO 






Co 

THE NATIONAL COMMITTEE FOR 

MENTAL HYGIENE 

AND 

ITS WORK IN 
WAR AND PEACE 



PREFACE 

This compilation was begun in the preparedness atmos- 
phere of the U. S. Army Neuropsychiatric Training School 
at Boston, 191 7-18. This particular school had to adapt 
itself to the clinical material of the Psychopathic Hospital. 
Although war cases early began to drift into the wards 
(even including some overseas material), it was thought 
well to supplement the ordinary "acute, curable, and in- 
cipient" mental cases of the hospital wards and out-patient 
service with representative cases from the literature. 

As time wore on, this "preparedness" ideal gave place 
to the ideal of a collection of cases to serve as a source-book 
for reconstructionists dealing with neuroses and psychoses. 
Shortage of medical staff and delays incidental to the influ- 
enza epidemic held the book back still further, and, as mean- 
time Brown and Williams had served the immediate need 
with their Neuropsychiatry and the War, it was determined 
to make the compilation the beginning of a case-history 
book on the neuropsychiatry of the war, following in part 
the traditions of various case-books in law and medicine. 

With the conclusion of the armistice, there is by no means 
an end of these problems. Peace-practice in neuropsychi- 
atry is bound to undergo great changes and improvements, 
if only from the influx into the peace-community of many 
more trained neuropsychiatrists than were ever before avail- 
able. This is particularly true in the American community 
by reason of the many good men specially trained in camp 
and hospital neuropsychiatry, both at home and in the 
A. E. F., through the enlightened policy of our army in 
establishing special divisions of the Surgeon-General's Office 
dealing separately with those problems. 

Though a book primarily for physicians, some of its mate- 
rial has interest for line-officers, who may see how much 
"criming" is matter for medical experts, by running through 
the boxed headings (especially of Sections A and B) and 



PREFACE 

reading the simulation cases. As Chavigny remarks, " shoot- 
ing madmen neither restrains crime nor sets a good example." 

But parts of the book look ahead to Reconstruction. 
Surely occupation-workers, vocationalists, war risk insurance 
experts, and in fact all reconstructionists, medical and lay, must 
find much to their advantage in the data of Section D (Treat- 
ment and Results). Had time permitted, the whole old 
story of "Railway Spine " — Shell-shock's congener — might 
have been covered in a series of cases from last century's 
literature, together with others illustrating the effects of 
suggestion and psychotherapy; but this must be a post- 
bellum task. 

The compiler, who has personally dictated (and as a rule 
redictated and twice condensed) all the cases from the originals 
(or in a few instances, e.g., Russian, from translations), hopes 
he has not added anything new to the accounts. The cases 
are drawn from the literature of the belligerents, 1914-1917, 
English, French, Italian, Russian, and — so far as available 
here — German and Austrian. 

I would call the collection not so much a posey of other 
men's flowers as a handful of their seeds. For I have con- 
stantly not so much transcribed men's general conclusions as 
borrowed their specific fine-print and footnotes. The lure 
of the 100 per cent has been very strong in many authors; but 
the test of fine-print, viz., of the actual case-protocols, saves 
us from premature conclusions, and the plan of the book 
allows us to confront actualities with actualities. One gets 
the impression of a dignified debate from the way in which 
case-histories automatically confront each other, say in 
Section C (Diagnosis). 

Obligations to the books of Babinski and Froment, Eder, 
Hurst, Mott (Lettsomian Lectures), Roussy and Lhermitte, 
Elliot Smith and Pear, and others are obvious. Yealland's 
book came too late for sampling its miracles, though cases of 
his in the periodical literature had already been incorporated 
in my selection. 

Some of the cases in Section A, 1, had already been ab- 
stracted in Neurosyphilis : Modern Systematic Diagnosis and 
Treatment (Southard and Solomon, 191 7). 



PREFACE 

What we actually have made is a case-history book in the 
newly combined fields now collectively termed neuropsy- 
chiatry. The more general the good general practitioner of 
medicine, the more of a neuropsychiatrist! And this is no 
pious wish or counsel of perfection. Neuropsychiatry, men- 
tal hygiene, psychotherapy and somatotherapy — all these will 
flourish intra-bellum and post-bellum, in days of destruction 
and in days of reconstruction. And who amongst us, medical 
or lay, will not have to deal in reconstruction days with cases 
like some here compiled? A minor blessing of the war will be 
the incorporation of mental hygiene in general medical prac- 
tice and in auxiliary fields of applied sociology, e.g., medi- 
co-social work. 

Subsidies aiding publication are due to the National 
Committee for Mental Hygiene; the Permanent Charity 
Foundation (Boston Safe Deposit and Trust Company); 
Mrs. Zoe D. Underhill of New York; Mr. H. T. White of 
New York; and Dr. W. N. Bullard of Boston— to all of 
these the various military recipients of the book will be under 
obligations, as well as others who would otherwise have had 
to pay the great maj oration de prix due to war times. 

Of those great dead contributors to neurology laid (in the 
Epicrisis) at the feet of the neo-Attila, perhaps only Sir 
Victor was in a narrow sense the Kaiser's victim: still, but 
for the war, they might all remain to us. 

By the way, just as I found John Milton had said things 
that fitted neurosyphilis, so also Dante is observed in the 
chosen mottoes to have had inklings even of Shell-shock. 
To the Inferno it was natural to turn for fitting mottoes 
(Carlyle's renderings mainly used). The pages might have 
been strewn with them. A glint of too great optimism might 
seem to shine — in the pre-Epicrisis motto — from the lance of 
Achilles with its " sad yet healing gift ; " but out of Shell-shock 
Man may get to know his own mind a little better, how under 
stress and strain the mind lags, blocks, twists, shrinks, and 
even splits, but on the whole is afterwards made good again. 

E. E. Southard, 

Washington, 
November, 1918. 



INTRODUCTION 

The duties of an introducer, whether of a platform speaker 
to an audience, or of a writer to his anticipated readers, are not 
always clearly denned. It has been sometimes said that the 
critic or reviewer may meet with better success if he has not 
acquainted himself too thoroughly with the contents of the 
book about which he writes, as in that case he will have a larger 
opportunity to indulge his imagination, but a critique thus pro- 
duced may have the disadvantage of possible shortcoming or 
unfairness. In the case of this volume, however, I have felt it 
worth while to acquaint myself with its contents, no light task 
when one is confronted with a thousand pages. 

The great war just closing has done much to enlighten us as 
to the causes, nature, outcome, and treatment of injuries and 
diseases to which its victims have been subjected. The object 
of this book is to present both the data and the principles in- 
volved in certain neuropsychiatry problems of the war. These 
are presented in a wealth of detail through an extraordinary 
series of case records (589 in all) drawn from current medical 
literature, during the first three years of the conflict. Case 
reporting is here seen at its best, and the experiences re- 
corded are largely allowed to speak for themselves, although 
comments are not wanting and are often illuminating. 

Many criticisms have been heard on the use of the term Shell- 
shock as applied to some of the most important psychiatric and 
neurological problems of the recent war; but that the designa- 
tion has meaning will be evident if Dr. Southard's book is not 
simply skimmed over by the reader, but is studied in its entirety. 
The symptoms of a very large number, if not the majority, of 
the cases recorded, had for their initiating influence the psychic 



VI INTRODUCTION 

and physical horrors of life among exploding shells. As the 
author and those from whom he has received his clinical supply 
not infrequently point out, in many cases it would appear that 
purely psychic influences have played the chief role, but in others 
physical injuries have not been lacking. Much more than this 
is true: in many instances the soil was prepared by previous 
defect, disease, or injury, or to use one of Dr. Southard's favorite 
expressions, "weak spots" were present before martial causes 
became operative. 

While the contributions to the medical and surgical history of 
the war have been somewhat numerous in current medical jour- 
nals and in monographs, few comprehensive volumes have ap- 
peared. The reasons for this are not far to seek. The conflict 
has been of such magnitude, and the demands on the bodily and 
mental activity of the medical profession have been so intense 
and continuous, that time and opportunity for the careful and 
complete recording of experiences have not been often available; 
but works are beginning to appear in the languages of all the 
belligerent countries and these will increase in number and 
value during the next lustrum and decade, although it may be 
that some of the most important contributions will come after a 
decade or more is past. The great work before me is one that 
will leave its lasting impress, not only upon military but on civil 
medicine, for the lessons to be drawn from its pages are in large 
part as applicable to the one as to the other. 

Looking backward to our Civil War, one is strongly impressed 
with the fact that the present volume, one of the earliest works 
of its kind to appear in book form, deals largely with psychiatry 
and functional nervous diseases, whereas during and after the 
American conflict the most important contributions to neurology 
related to organic disease, especially as illustrated by the work 
of Weir Mitchell and his collaborators on injuries of nerves. 
This is the more interesting when it is remembered that Mitchell 
not very long after the close of the Civil War became the most 
prominent exponent of functional neurology, from the diagnostic 



INTRODUCTION VII 

f 

and therapeutic sides. To him the profession the world over has 
been indebted for the development of new views as to the nature 
of neurasthenia and hysteria and new methods for combating 
these disorders. In this fact is to be found matter for thought. 
Those who handled best the neuropsychiatric problems of the 
present war were in large part qualified not merely by a knowl- 
edge of psychology and psychiatry, but far more by a thorough 
training in organic neurology. The problems of psychiatry can 
be grasped fully only by those who have a fundamental knowl- 
edge of the anatomy, physiology, and diseases of the nervous 
system. 

Dr. Southard, preeminently a neuropathologist, is well 
grounded in organic neurology, and shows at every turn his 
capabilities for considering the neuroses, psychoses, and insani- 
ties from the standpoint of the neurologist. Moreover, he 
clearly shows training and insight into the problems of non- 
neurological internal medicine. 

The ideal method of training a student for neuropsychiatric 
work — if one had the opportunity of directing his course 
from the time of his entry into medicine — would be to see to 
it, after a good grounding in the fundamental sciences like 
anatomy, physiology, and chemistry, that medicine and surgery 
in their broadest phases first received school and hospital atten- 
tion; that the fields of neurology, pure and applied, were then 
fully explored; and that psychology and psychiatry received late 
but thorough consideration. When after America's entrance into 
the world war the writer assisted in preparing medical reserve 
officers for neuropsychiatric service, those men did best both 
during their postgraduate work and in base hospitals and in 
the field, who had built from the bottom after the manner in- 
dicated. 

At the outset of Dr. Southard's book, for more than two hun- 
dred and fifty pages, the author considers under ten subdivisions 
the acquired diseases and constitutional defects which may pre- 
dispose the soldier to functional and reflex nervous disease. 



Vlll INTRODUCTION 

Neurosyphilis, on which Dr. Southard and Dr. Solomon have 
already given us a valuable treatise, the pharmacopsychoses, 
especially alcoholism, and the somatopsychoses covering fevers 
like typhoid and paratyphoid, are considered in numerous care- 
fully chosen case reports. The reader needs only to look closely 
into the case records of the first quarter of the volume to get a 
knowledge of the affections chiefly predisposing the soldier or 
civilian to functional and reflex nervous diseases. To those 
familiar with the medical history of the war it is well known 
that one of the reasons for the efficiency of the American Ex- 
peditionary Force resided in the fact that the preHminary 
examinations of the recruits received the fullest attention not 
only from the points of view of acquired and inherited disease, 
but also from those of special psychiatric and even psychological 
deficiencies. Our country, however, had for its guidance the 
experience of nations which were fighting for three years before 
we entered the arena and in addition had a large surplus of 
material from which to cull out the weaklings. 

Among the predispositional affections considered — besides 
syphilis, alcohol, and other drug habits, and the somatopsychoses 
— are the feeble -mindednesses or hypophrenoses, the epilepsies, 
the psychoses due to focal brain lesions, the presenile and senile 
disorders, the schizophrenoses including dementia praecox and 
allied affections, the cyclothymoses like manic depressive insan- 
ity, the psychoneuroses, and the psychopathoses. The last two 
subjects indicated, considered in special chapters, seem to some 
extent to be receptacles for affections which cannot well be 
otherwise placed, — hallucinoses, hysteria, neurasthenia, and psy- 
chasthenia, — and under the psychopathoses, pathological lying, 
Bolshevism, delinquencies of various sorts, homosexuality, suicide 
and self-mutilation, nosophobia, and even claustrophobia with 
its exemplar who preferred exposure to shell-fire to remaining in 
a tunnel. 

Under the encephalopsychoses are found interesting illustra- 
tions of focal lesions and the general effects of infection and 



INTRODUCTION IX 

/ 

toxemia. Cases of brain abscess, of spinal focal lesions, and 
meningeal hemorrhage are in evidence, aphasias, monoplegias, 
Jacksonian spasm, and thalamic disease receiving consideration. 

All neurologists know the difficulties in diagnosticating epilepsy 
in the absence of opportunities to see attacks and to receive the 
carefully analyzed statement of the observers of the patient. 
All this and much more is well brought out in the chapter on the 
epileptoses. Many epileptics found their way into the armies 
either through the carelessness of examiners or by suppression of 
the facts on the part of those who desired to serve. 

The fact that an imbecile can shoot straight and face fire 
comes out in one or two places, but this does not seem to prove 
that a good rifleman is necessarily an all-round good soldier. 

A book like Dr. Southard's could be made of much use in 
teaching students, especially postgraduates, by having them, 
when a particular subject like epilepsy or schizophrenia, for in- 
stance, is under discussion, use as collateral reading the case 
reports of this work. 

Dr. Southard's book will prove useful to many workers — to 
the medical officer whose duty it is to examine recruits for the 
service or to pass upon and treat them while in service; almost 
equally to the medical officer in time of peace; to authors of text- 
books and treatises and to contributors to neurological and psy- 
chiatric journals; to lecturers and clinical demonstrators; to 
the examiner for the juvenile courts; and to members of the 
psychopathic, psychiatric, and neurological staffs of our 
hospitals. 

One is not called upon in an introduction to review at length 
the contents of the volume, but it may prove of value to the 
reader to dip here and there into the pages of the work to which 
his attention is being invited. 

It will be remembered that fifty years ago and much later, 
down to the time of Babinski's active propaganda in favor of 
the theories of suggestion, counter-suggestion, and persuasion in 
hysteria, various affections of a vasomotor and thermic type 



X INTRODUCTION 

were included in the list of hysterical phenomena. These and 
some other phenomena sometimes classed as hysterical, Babinski 
and those who accord with him now find it necessary to sweep 
entirely from the domain of hysteria, which being produced by 
suggestion and cured by counter-suggestion or persuasion cannot 
include symptoms which are beyond the control of the will and 
intellect of the patient. 

According to the new or rather revived pronouncement, these 
must be due either to definite organic lesion, or to a disorder of 
reflex origin, connoting the occurrence of changes in the nervous 
centers as long ago taught by Vulpian and Charcot. In the 
records of cases and in the discussions thereon this differentia- 
tion receives much consideration. 

It is held that the paralysis in the reflex cases is more limited, 
more persistent, and assumes special forms not observable in 
hysteria. The attitudes in hysterical palsies conform more to 
the natural positions of the limbs than do those observed in 
reflex paralysis. Probably the presence of marked amyotrophies 
in the reflex nervous disorders is the most convincing factor in 
separating these from pithiatic affections. These atrophies cor- 
respond to the arthritic muscular atrophies of Vulpian, Charcot, 
Gowers, and others, and cannot for a moment be regarded as 
caused by suggestion or as removable by counter-suggestion or 
persuasion. They are influenced, discounting the effect of time 
and natural recuperation, only by methods of treatment de- 
signed to improve the peripheral and central nutrition of the 
patient. Pithiatic atrophies are slight and probably always to 
be accounted for by disuse or the association of some peripheral 
neural disorder with the hysteria. Affections of the sudatory 
and pilatory systems are more definitely pronounced in reflex 
cases than in those of a strictly hysterical character. 

Some of the facts brought forward by Babinski and Froment 
to demonstrate the differentiation of reflex paralyses from pithia- 
tic disorders of motion are challenged in the records of this 
volume by others, as for instance, by Dejerine, Roussy, Marie, 



INTRODUCTION XI 

and Guillain. Babinski tells us that in pithiatism, properly rio 
designated, the tendon reflexes are not affected. He believes 
that even in pronounced anesthesia of the lower extremities the 
plantar reflexes can always be elicited and are not abnormal in 
exhibition. Dejerine, however, produces cases to illustrate the 
fact that in marked hysterical anesthesia of the feet plantar 
responses cannot be produced. I have personally studied cases 
which lend some strength to either contention. In some of 
these I was not able to conclude that either the use of the will 
or the presence of contractions in extension was sufficient to 
exclude the normal responses. 

Differences in muscle tonicity, in mechanical irritability of 
the muscles, and the presence or absence of fibrotendinous con- 
tractions are indications of a separation between the reflex and 
purely functional cases, as apparently demonstrated in some of 
the case records. True trophic disorders of the skin, hair, and 
bones observed in the reflex cases are also said to have no place 
in the illustrations of pithiatism. 

The delver into the case histories of this volume will find nu- 
merous instructive combinations of hystero-reflex and organo- 
hysterical associations which are not to be enumerated in an 
introduction. The great importance of what all recognize as 
pathognomonic signs of organic disease — Babinski extensor toe 
response, persistent foot clonus, reactions of degeneration, 
marked atrophy, lost tendon jerks, etc. — is, of course, continu- 
ously in evidence. Extraordinary associations of hysterical, 
organic, and reflex disorders with other affections due to direct 
involvement of bone, muscle, and vessels and with the second- 
ary effects of cicatrization and immobilization are brought out 
on many pages. In quitting this branch of our subject it might 
be remarked that considerable changes must be made in our 
textbook descriptions of nervous diseases in the light of the con- 
tributions to the neurology of the present war. 

One is reminded in the details of some of the cases of the dis- 
cussions some decades since on the subject of spinal traumatisms; 



XU INTRODUCTION 

of the work of Erichsen which resulted in giving his name and 
that of " railway spine" to many of the cases now commonly 
spoken of as traumatic hysteria and traumatic neurasthenia; of 
the rejoinders of Page and his views regarding spinal trauma- 
tisms; and of Oppenheim's development of the symptom com- 
plex of what he prefers to term the traumatic neurosis. One 
who has taken part in much court work cannot but read these 
case records with interest, for the neurology of the war as pre- 
sented in this volume and in numerous monographs which are 
now appearing, throws much light upon many often mooted 
medicolegal problems. I recall how many able and honest neu- 
rological observers have changed their points of view since the 
early days of Erichsen's " railway spine," a pathological sugges- 
tion which is said to have cost the corporations of England an 
almost fabulous sum during a score of years. I recall also that 
a certain Court of Appeals in one of our states even felt itself 
called upon to promulgate an opinion intended to exorcise en- 
tirely the plea for damages for alleged injuries if it could be 
shown that these were due to fright. The data of this book do 
not put weapons entirely into the hands of the attorney and 
the expert for either the plaintiff or the defendant. 

Some of the French writers on the neurology of the war, as 
illustrated in the records collected by Dr. Southard, have brought 
to our attention distinctions which they draw between etats 
commotionnels and etats emotionnels — happy terms, and yet not 
sufficient in their invention or in the explanations which ac- 
company them, fully to satisfy the requirements of the facts 
presented. These writers seem to think of the commotional 
states as denoting some real disease or condition of the brain, 
and yet one which is really curable and reversible. They ex- 
plicitly tell us, however, that these commotions fall short of 
being lesionnel. After all, is this not somewhat obscure? Is it 
not something of a return to the period of " railway spine" 
when one of the comparisons sometimes made was that the 
injury suffered by the nervous tissues produced in them a state 



INTRODUCTION xiii 

comparable to that of a magnet which had been subjected to a^ 
severe blow? At any rate, in commotion thus discussed the 
nervous structures are supposed to sustain some real injury of a 
physio chemical character, whereas in the emotional states the 
neurones are, as Southard puts it, affected somewhat after the 
manner of normal emotional functioning, except perhaps that 
they are called upon to deliver an excessive stream of impulses. 
The latter would be classed among the psychopathic, the former 
among the physiopathic affections, and yet the distinction be- 
tween the two is not always quite clear. 

In not a few instances of Shell-shock — although these are 
not numerous, so far as records have been obtained — actual 
structural lesions have been recorded even in cases in which no 
direct external injury of a material kind was experienced as a 
result of the explosion of shells. In others the evidences of 
external injury were relatively unimportant. Various lesions, in 
some cases recognizable even by the naked eye, were present. 
Mott, for example, found not only minute hemorrhages, but in 
one instance a bulbar extravasation of moderate massiveness, 
the patient not showing external signs of injury. Cases are also 
recorded of hematomyelia; others with edematous or necrotic 
areas in the cord; and still others with lesions of the ependyma 
or even with splitting of the spinal canal, reminding one of the 
classical experiments of Duret on cerebral and cerebrospinal 
traumatisms. 

It has been argued that too much stress should not be laid 
on a few cases of this sort — but are they as few as they seem 
to be? The fact is that necropsical opportunities are not often 
afforded. May not such scattered lesions often be present with- 
out resulting in death or even in long continued disturbance? 
There is no essential reason why minute hemorrhages into the 
brain and spinal cord, and especially into their membranes, may 
not undergo rapid absorption or even remain unchanged for 
some time without dire results. 

One of the reported cases in which lung splitting occurred from 



XIV INTRODUCTION 

severe concussion without external injury is not without interest 
in this connection, reminding one, as the commentator says, of 
those cases of severe concussion in which the interior of a build- 
ing is injured while the exterior escapes. In the same connec- 
tion also the cited experiments of Mairet and Durante on rabbits 
are not without instructiveness. As a result of explosives set off 
close to these animals, pulmonary apoplexy, spinal cord and root 
hemorrhages, and extravasations, perivascular and ependymal, 
and into the cortical and bulbar gray were found. Russca ob- 
tained direct and contrecoup brain lesions, etc., in a similar way. 

Here and there throughout the book will be found references 
to symptoms and syndromes which will have a particular inter- 
est for the reader — soldier's heart, trench foot, congealed hand, 
tics, tremors, convulsions, sensory areas variously mapped, and 
forms of local tetanus, the last being distinctly to be differen- 
tiated from pithiatic contractures and those due to organic 
lesions of the nervous system. Cases of an affection described 
by Souques as camptocormia, from Greek words meaning to 
bend the trunk, were shown to the Neurological Society of Paris 
in 1 9 14 and later, the main features of this affection being pro- 
nounced incurvation forward of the trunk from the dorsolumbar 
region, with extreme abduction and outward rotation of the 
lower limbs, pain in the back, and difficult and tremulous walk- 
ing. In some of these cases, organic lesions of the trunkal tissues 
were present, but in addition psychic elements played a not un- 
important part, and the cases were restored to health by a com- 
bination of physical measures with psychotherapy, enforced by 
electrical applications. 

The part of this book given over to the discussion of treat- 
ment will doubtless to some prove the most interesting section. 
The presentation of the subject of therapeutics is in some degree 
a discussion also of diagnosis and prognosis; and so it happens in 
various parts of the volume that the particular subject under 
consideration is more or less a reaffirmation or anticipation of 
remarks under other headings. 



INTRODUCTION XV 

y 

Similar results are brought about by various therapeutic pro- 
cedures. Nonne, Myers, and a few others bring hypnosis into 
the foreground, although non-hypnotic suggestion plays a larger 
role by far. 

Miracle cures are wrought through many pages. Mutism, 
deafness and blindness, palsies, contractures, and tics disappear 
at times as if by magic under various forms of suggestion. Ether 
or chloroform narcosis drives out the malady at the moment 
when it reveals its true nature. Verbal suggestion has many 
adjuvants and collaborators — electricity, sometimes severely 
administered, lumbar puncture, injections of stovaine into the 
cerebrospinal fluid, injections of saline solution, colored lights, 
vibrations, active mechanotherapy, hydrotherapy, hot air baths 
and blasts, massage, etc. Painful and punitive measures have 
their place — one is inclined to think a less valuable place than 
is given them by some of the recorders. In some instances the 
element of suggestion, while doubtless present, is overshadowed 
by the material methods employed. Persuasion and actual 
physical improvement are in these cases highly important. Re- 
education is not infrequently in evidence. The patient in one 
way or another is taught how to do things which he had lost 
the way of doing. 

It is interesting to American neurologists to note how fre- 
quently in the reports, especially of French observers, the "Weir 
Mitchell treatment" was the method employed, including isola- 
tion, the faradic current, massage, and Swedish movements, hydro- 
therapy, dietetic measures, reeducative processes, and powerful 
suggestion variously exhibited, especially through the mastery 
of the physician over the patient. It is rather striking that few 
records of Freudian psychoanalytic therapy are presented. 

When all is said, however, counter-suggestion and persuasion, 
in whatever guise made use of, were not always sufficient and 
this not only in the clearly organic cases, but in those which are 
ranked under the head of reflex nervous disorders. In these the 
long-continued use of physical agencies was found necessary to 



XVI INTRODUCTION 

supplement the purely psychic procedures, these facts some- 
times giving rise in the Paris Society of Neurology and elsewhere 
to animated discussion as to the real nature of the cases. The 
pithiatic features of the case at times disappear, but leave be- 
hind much to be explained and more to be accomplished. The 
cures wrought are not always permanent and in some cases post- 
bellum experiences may be required to prove the real value of 
the measures advocated. The reader must study well the de- 
tailed records in order to arrive at just conclusions; neverthe- 
less, the tremendous efficacy of suggestion and persuasion stands 
out in many of the recitals. 

Perhaps the author may permit the introducer a little liberty 
of comment. His non-English interpellations, especially Latin 
and French, may be regarded by some as overdone or perhaps 
pedantic, but are rather piquant, giving zest to the text. Diagno- 
sis per exclusionem in ordine is sonorous and has a scholarly 
flavor, but does not prevent the reader who lives beyond the 
faubourgs of Boston from understanding that the author is speak- 
ing of an ancient and well-tried method of differential diagnosis. 
Passim may be more impressive or thought-fixing than its English 
translation, but this to the reader will simply prove a matter of 
individual opinion. Psychopathia martialis is not only mouth- 
filling like Senegambia or Mesopotamia, but really has a claim to 
appreciation through its evident applicability. It is agreeable 
to note that the book seems nowhere to indicate that psycho- 
pathia sexualis and psychopathia martialis are convertible terms. 

The bibliography of the volume challenges admiration because 
of its magnitude and thoroughness and is largely to be credited, 
as the author indicates, to the energy and efficiency of Sergeant 
Norman Fenton, who did the work in connection with the Neu- 
ropsychiatric Training School at Boston, resorting first-hand to 
the Boston Medical Library and the Library of the New York 
Academy of Medicine. After Sergeant Fenton joined the Ameri- 
can Expeditionary Force, Dr. Southard greatly increased the 
value of the bibliography by his personal efforts. 



INTRODUCTION xvii 

This bibliography covers not only the 589 case histories of the 
book, but it goes beyond this, especially in the presentation of 
references for 1917, 1918, and even 191 9. Owing to the time 
when our country entered the war, American references are, in 
the main, of later date than the case histories. They will be 
found none the less of value to the student of neuropsychiatric 
problems. 

The references in the bibliography number in all more than 
two thousand, distributed so far as nationalities are concerned 
about as given below, although some mistakes may have crept 
into this enumeration for various reasons, like the publication of 
the same articles in the journals of different countries. The list 
of references includes French, 895; British (English and Co- 
lonial), 396; Italian, 77; Russian, 100; American, 253; Spanish, 
5; Dutch, 5; Scandinavian, 5; and Austrian and German, 476. 
It will be seen, therefore, that the bibliography covers in number 
nearly four times the collected case studies, most of these records 
being from reports made during the first three years of the war. 
The author has wisely made an effort to bring the bibliographic 
work up to and partially including 191 9. 

The manner in which the French neurologists and alienists 
continued their work during the strenuous days of the terrible 
conflict is worthy of all praise. The labors of the Society of 
Neurology of Paris never flagged, its contributions in current 
medical journals having become familiar to neurologists who 
have followed closely the trend of medical events during the 
war. Cases and subjects were also frequently presented and 
discussed at the neurological centers connected with the French 
and allied armies in France. 

It may be almost invidious to specify names, the work done 
by many was of so much interest and value. Dejerine in the 
early days of the war, before his untimely sickness and death, 
contributed his part. Marie from the beginning to the end of 
the conflict continued to make the neurological world his debtor. 
The name of Babinski stands out in striking relief. Other 






XV111 INTRODUCTION 

names frequently appearing among the French contributors are 
those of Froment, Clovis Vincent, Roussy and Lhermitte, Leri, 
Guillain, Souques, Laignel-Lavastine, Courbon, Grasset, Claude, 
Barre, Benisty, Foix, Chavigny, Charpentier, Meige, Thomas, 
and Sollier. 

For a work of this character not only as complete a bibliog- 
raphy as possible, but a thorough index is absolutely necessary, 
and this has been supplied. The author has not made the index 
too full, but with enough cross references to enable those in all 
lines of medical work interested to cull out the cases and com- 
ments which most concern them. 

My prologue finished, I step aside for the play and the player, 
with the recommendation to the reader that he give close heed 
to the performance — to the recital of the cases, the comments 
thereon, and the general discussion of subjects — knowing that 
such attention will be fully rewarded, for in this wonderful col- 
lection of Dr. Southard is to be seen an epitome of war neurology 
not elsewhere to be found. 

Charles K. Mills. 

Philadelphia, May, 1919. 



TABLE OF CONTENTS 

SECTION A. PSYCHOSES INCIDENTAL IN THE WAR 

I. The Syphilitic Group (Syphilopsychoses) 

Case Page 

i. Desertion of an officer Briand, 1915 .... 8 

2. Visions of a naval officer Carlill, Fildes, Baker, 1917 9 

3. Aggravation of neurosyphilis by war Weygandt, 1915 .... 10 

4. Same Hurst, 1917 . ... 10 

5. Same Beaton, 1915. . . .10 

6. Same Boucherot, 1915 .... n 

7. Same Todd, 1917. ... 12 

8. Same Farrar, 1917 . ... 13 

9. Same Marie, Chatelin, Patrikios, 1917 . ... 14 

10. Root-sciatica Long, 1916. . . .15 

II. Disciplinary : Kastan, 1916. ... 17 

12. Same Kastan, 1916. . . .18 

13. Same? Kastan, 1916 .... 19 

14. Hysterical chorea versus neurosyphilis de Massary, du Sonich, 191 7 20 

15. Traumatic general paresis Hurst, 1917 . . . . 22 

16. Head trauma; shell-shock; mania; W. R. positive . Babonneix, David, 191 7 23 

17. Head trauma in a syphilitic Babonneix, David, 1917. ... 24 

18. Shell wound: general paresis Boucherot, 1915 .... 25 

19. "Shell-shock" ocular palsy: syphilitic Schuster, 1915 26 

20. Shell-shock: general paresis Donath, 1915 .... 27 

21. Shell-shock: tabes Logre, 1917 . ... 28 

22. Same Duco, Blum, 1917 .... 28 

23. Pseudotabes (Shell-shock) Pitres, Marchand, 19 16. ... 29 

24. Shell-shock neurosyphilis Hurst, 1917 . ... 30 

25. Shell-shock neurosyphilis Hurst, 1917 . ... 31 

26. Pseudoparesis (Shell-shock) Pitres, Marchand, 1916 32 

27. War strain and Shell-shock in a syphilitic Karplus, 1915 ... .34 

28. Shell-shock recurrence of syphilitic hemiplegia Mairet, Pieron, 1915 36 

29. Shell-shock (functional!) amaurosis in a neurosyphilitic 

Laignel-Lavastine, Courbon, 1916. . . .37 

30. Shell-shock (functional) phenomena in a neurosyphilitic 

Babonneix, David, 191 7. • • -39 
51. Vestibular symptoms in a neurosyphilitic Guillain, Barre, 19 16 40 



XX TABLE OF CONTENTS 

Case Page 

32. Syphilophobic suicidal attempts Colin, Lautier, 19*7 41 

33. Simulated chancre Pick, 1916. . . .42 

34. Exaggeration Buscaino, Coppola, 1916 43 



II. The Feeble-minded Group (Hypophrenoses) 

35. A feeble-minded person fit for service Pruvost, 1915 

36. An imbecile superbrave Pruvost, 1915 

37. An imbecile fit for barracks work .Pruvost, 1915 

38. A feeble-minded inventor Laignel-Lavastine, Ballet, 191 7 

39. A feeble-minded simulator Pruvost, 1915 

40. Enlistment for amelioration of character Briand, 191 5 

41. An imbecile fit for service at the front Pruvost, 1915 

42. An imbecile with sudden initiative Lautier, 19 15 

43. Emotional fugue in subnormal subject Briand, 1915 

44. Regimental surgeon versus alienist re feeble-mindedness Kastan, 19 16 

45. An imbecile rifleman Kastan, 1916 

46. An imbecile hypomaniacal Haury, 1915 

47. Feeble-minded desire to remain at the front Kastan, 1916 

48. An imbecile sent back by Germans Lautier, 1915 

49. Unfit for service: feeble-mindedness? • Kastan, 1916 

50. Oniric delirium in a feeble-minded subject Soukhanoff, 19 15 

51. Shell-shock and burial: situation not rationalized Duprat, 1917 

52. Shell-shock in weak-minded subject; fear, fugues. .Pactet, Bonhomme, 1917 

III. The Epileptic Group (Epileptoses) 

53. Epilepsy: neurosyphilis Hewat, 1917 

54. Epilepsy brought out by syphilis Bonhoeffer, 19 15 

55. Syphilis in a psychopathic subject Bonhoeffer, 1915 

56. Epileptic imbecile court-martialed Lautier, 1916 

57. Psychogenic seizures in feeble-minded subject Bonhoeffer, 1915 

58. Drunken epileptic: responsibility? Juquelier, 1917 

59. Epilepsy: disciplinary case Pellacani, 1917 

60. Same Pellacani, 1917 

61. Desertion: epileptic fugue Verger, 1916 

62. Specialist in escapes Logre, 1917 

63. Epilepsy and other factors: disciplinary case Consiglio, 191 7 

64. Strange conduct and amnesia in epileptic Hurst, 191 7 

65. Epilepsy after antityphoid inoculation Bonhoeffer, 1915 

66. Shell-shock: Jacksonian seizures — decompression Leriche, 191 5 

67. Blow on head: hysterical convulsions — cure by neglect Clarke, 1916 

68. Epilepsy with superposed hysteria Bonhoeffer, 1915 

69. Musculocutaneous neuritis: Brown-Sequard's epilepsy 

Mairet, Pier on, 19 16 

70. Bullet wound: reactive epilepsy? Bonhoeffer, 1915 



•65 
.66 
.67 
.68 
.69 
•7i 
•74 
•76 
•78 
.80 
.82 
■83 
.84 
.86 
.87 



89 
.92 



Case p 

71. Epilepsia tarda Bonhoeffer, 1915 

72. Convulsions by auto-suggestion Hurst, 1916 

73. Epilepsy, emotional Westphal, Hiibner, 1915 

74. Hysterical convulsions Laignel-Lavastine, Fay, 191 7 

75. Desertion: fugue, probably not epileptic Barat, 1914 

76. Epileptic episode Bonhoeffer, 1915 

77. Narcoleptic seizures Friedmann, 1915 

78. Sham fits Hurst, 1917 

79. Epileptoid attacks controllable by will Russel, 191 7 

80. Epileptic taint brought out at last by shell-shock Hurst, 191 7 

81. Shell-shock epilepsia larvata Juquelier, Quellien, 19 17 

82. To illustrate a theory of Shell-shock as epileptic Ballard, 1915 

83. Same Ballard, 1917 

84. Same Ballard, 1917 

85. Epileptic equivalents Mott, 1916 

IV. The Alcohol-Drug-Poison Group (Pharmacopsychoses) 

86. Pathological intoxication Boucherot, 1915 ... 113 

87. Same Loewy, 1915 ... 116 

88. Desertion in alcoholism: fugue Logre, 1916. . . 117 

89. Alcoholic amnesia experimentally reproduced Kaslan, 1915 . . . 118 

90. Desertion and drunkenness Kastan, 1915 ... 119 

91. Desertion by alcoholic dement Kastan, 1915 . . . 121 

92. Desertion by alcoholic with other factors Kastan, 1915 . . . 124 

93. Alcoholism: disciplinary case Kastan, 1915 . . . 126 

94. Atrocity, alcoholism Kaslan, 1915 . . . 127 

95. Atrocity, alcoholic Kastan, 1915 . . . 128 

96. Alcoholism and amnesia: disciplinary case Kastan, 1915. . . 129 

97. Post- traumatic intolerance of alcohol Kastan, 1915 . . . 130 

98. Adventure with Parisian stranger Briand, Haury, 1915 . . . 131 

99. Morphinism: tetanus Briand, 1914- ■ • J3 1 

100. Morphinism: medicolegal question Briand, 1914- • • x 3 2 

101. [.Two morphinists Briand, 1914. . . 132 

102. \ 

V. The Focal Brain Lesion Group {Eneephalo psychoses) 

103. Aphasia and left hemiplegia: local and contrecoup lesions . . L'Hermitte, 1916 . . . 133 

104. Gunshot head wound and alcohol: amnesia Kastan, 1916 . . . 135 

105. Bullet in brain: cortical blindness and hallucinations 

Lereboullet, Mouzon, 191 7 . . . 136 

106. Content of existent psychosis changed by head trauma 

Laignel-Lavastine, Courbon, 191 7 . . .139 

107. Meningococcus meningitis; apparent recovery: dementing psychosis 

Maixandeau, 1915 . . . 14 1 



XX11 TABLE OE CONTENTS 

Case Page 

108. Meningococcus meningitis Eschbach and Lacaze, 1915 . . . 143 

109. Shell-shock: meningitic syndrome Pitres and Marchand, 1916. . . 145 

no. Brain abscess in a syphilitic: matutinal loss of knee-jerks 

Dumolard, Rebierre, Quellien, 19 15 . . . 147 
in. Spinal cord lesion: early recovery Mendelssohn, 1916. . . 149 

112. Shell explosion and meningeal hemorrhage: pneumococcus meningitis 

Guillain, Barre, 1917. . . 150 

1 13. Ante bellum cortex lesion : shrapnel wound determines athetosis . Batten, 1916. . . 15 1 

114. Hysterical versus thalamic hemianesthesia Leri, 1916. . . 152 

115. Shell-shock: multiple sclerosis syndrome Pitres, Marchand, 1916. . . 154 

116. Mine explosion: hysterical and organic symptoms Smyly, 1917 . . . 156 

117. Same Smyly, 1917 . . . 156 

VI. The Symptomatic Group (Somatopsychoses) 

118. Rabies: neuropsychiatric phenomena 

Grenier de Cardenal, Legrand, Benoit, 191 7. . . 162 

119. Tetanus, psychotic Lumiere, Astier, 1917 . . . 164 

120. Tetanus fruste versus hysteria Claude, L'Hermitte, 1915 . . . 165 

121. British officer's letter concerning local tetanus Turrell, 1917 . . . 166 

122. Dysentery: psychosis Loewy, 1915 . . . 168 

123. Typhoid fever: hysteria Sterz, 1914 . . . 169 

124. Dementia praecox versus posttyphoid encephalitis Nordmann, 1916. . . 170 

125. Paratyphoid fever: psychosis outlasting fever Merklen, 1915 . . . 171 

126. Paratyphoid fever : psychopathic taint brought out Merklen, 19 15 . . . 172 

127. Diphtheria: postdiphtheritic symptoms Marchand, 1916. . . 173 

128. Diphtheria: hysterical paraparesis Marchand, 1915 . . . 174 

129. Malaria: amnesia De Brun, 1917 . . . 175 

130. Malaria: Korsakow's syndrome Carlill, 1917. . . 176 

131. Malaria: ventral horn symptoms Blin, 1916 . . .178 

132. Trench foot; acroparesthesia Cottet, 191 7 . . . 180 

133. Bullet injury of spine; bronchopneumonia: etat crible of spinal cord 

Roussy, 1916 . . . 181 

134. Shell-shock (shell not seen); sensory and motor symptoms: decubitus; 

recovery Heitz, 1915 ... 183 

135. Shell-shock; later typhoid fever: neuritis {ante bellum hysteria) 

Roussy, 1915 . . . 185 

136. Bullet wound of pleura: hemiplegia and ulnar syndrome 

Phocas, Gutmann, 1915 . . . 186 

137. Tachypnea, hysterical Gaillard, 1915 . . . 188 

138. Soldiers' heart Parkinson, 1916. . . 190 

139. Soldiers' heart? Parkinson, 1916. . . 191 

140. War strain and shell wound: diabetes mellitus Karplus, 191 5 . . . 192 

141. Dercum's disease Hollande, Marchand, 1917 . . . 193 

142. Hyperthyroidism Tombleson, 1917 . . . 195 



TABLE OF CONTENTS xxiii 



Case Pa 

143. Hyperthyroidism?, neurasthenia Dejerine, Gascuel, 1914. . .196 

144. Hyperthyroidism Rothacker, 1916 ... 197 

145. Graves' disease, forme fruste Babonneix, Celos, 1917. . . 198 

146. Shell-shock hysteria: surgical complications Oppenheim, 1915. . .199 

VII. The Presenile and Senile Group (Gerio psychoses) — No cases. 

VIII. The Dementia Praecox Group (Schizophrenoses) 

147. Hatred of Prussia: diagnosis, dementia praecox Bonhoeffer, 1916. . . 200 

148. Dementia praecox: arrest as spy Kastan, 1915 . . . 201 

149. Fugue, catatonic Boucherot, 1915 . . . 203 

150. Desertion: schizophrenic? Consiglio, 1916. . . 204 

151. Schizophrenia; alcoholism: disciplinary case Kastan, 1915 . . . 206 

152. Schizophrenia aggravated by service d e la Motte, 1915 . . . 208 

153. Shot himself in hand: delusions Rouge, 1915 . . . 209 

154. Dementia praecox volunteer Haury, 1915 ... 210 

155. Hysteria versus catatonia Bonhoeffer, 1916 . . . 211 

156. "Hysteria" actually dementia praecox Hoven, 1915 . . . 213 

157. Hallucinatory and delusional contents influenced by war experiences 

Gerver, 1915. . .214 

158. Iron cross winner, hebephrenic Bonhoeffer, 1915 . . . 215 

159. Occipital trauma; visual hallucinations Claude, UHermitte, 1915 . . . 217 

160. Shell-shock: Dementia praecox Weygandt, 1915 . . . 219 

161. Same Dupuoy, 1915 . . . 220 

162. Shell-shock; fatigue; fugue; delusions Rouge, 1915 . . . 221 

IX. The Manic-Depressive Group (Cyclothymoses) 

163. A maniacal volunteer Boucherot, 1915 . . . 222 

164. Fugue, melancholic Logre, 1917. . . 223 

165. Apples in No-man's-land Weygandt, 1914. . . 224 

166. Trench life: depression; hallucinations; arteriosclerosis; age, 38 

Gerver, 1915. . .225 

167. War stress: manic depressive psychosis Dumesnil, 19 15 . . . 226 

168. Predisposition; war stress: melancholia Dumesnil, 1915 . . . 227 

169. Depression; low blood pressure; pituitrin Green, 1916. . . 228 

X. The Psychoneurotic Group (Psychoneuroses) 

170. Three phases in a psychopath Laignel-Lavastine, Courbon, 191 7. . .229 

171. Fugue, probably hysterical Milian, 1915 . . . 232 

172. Hysterical Adventist de la Motte, 1915 ... 234 

173. Fugue, psychoneurotic Logre, . . . 235 

174. Shell-shy; war bride pregnant: fugue with amnesia and mutism 

Myers, 1916 . . . 236 

175. A neurasthenic volunteer E. Smith, 1916 . . . 237 



XXIV TABLE OF CONTENTS 

Case Page 

176. War stress: neurasthenia in subject without heredity or soil. .Jolly, 1916. . .238 

177. Arterial hypotension in psychasthenia Crouzon, 1915 . . . 239 

178. War stress: psychasthenia Eder, 1916 . . . 240 

179. Ante helium attacks: neurasthenia Binswanger, 19 15 . . . 241 

180. Antityphoid inoculation: neurasthenia Consiglio, 191 7 . . . 244 

181. Neurasthenia (one symptom: sympathy with the enemy) . . .Steiner, 1915 ... 245 

XI. The Psychopathic Group (Psycho pathoses) 

182. Claustrophobia: shells preferred to tunnel Steiner, 1915 . . . 246 

183. Pathological liar Henderson, 1917 . . . 247 

184. Psychopath almost Bolshevik Hoven, 1917. . . 249 

185. Hysterical mutism: persistent delusional psychosis Dumesnil, 191 5. . .250 

186. Psychopathic inferiority brought out by the war . . . « Bennati, 1916. . . 251 

187. Psychopathic episodes Pellacani, 1917 . . . 252 

188. Maniacal and hysterical delinquent Buscaino, Coppola, 1916. . . 253 

189. Psychopathic delinquent Buscaino, Coppola, 1916 . . . 254 

190. Psychopathic excitement ■ Buscaino, Coppola, 1916 . . . 255 

191. Desertion: dromomania Consiglio, 1917. . . 256 

192. Suppressed homosexuality R. P. Smith, 1916. . . 257 

193. Psychopathic: at first suicidal, then self-mutilative MacCurdy, 191 7. . . 258 

194. Bombardment: psychasthenia Laignel-Lavastine, Courbon, 191 7. . .259 

195. Nosophobia Colin, Lautier, 1917 . . . 261 

196. Psychopath: Attacks of disgust and terror Lattes, Goria, 1915 ... 262 

SECTION B. SHELL-SHOCK: NATURE AND CAUSES 

197. Shell explosion: Autopsy — hemorrhages; vagoaccessorius chroma- 

tolysis Mott, 1917. . .265 

198. Mine explosion: Autopsy — hemorrhages Chavigny, 1916 . . . 270 

199. Mine explosion: Autopsy — hemorrhages Roussy, Boisseau, 1916 . . . 271 

200. Shell fragment in back: Autopsy — softenings in spinal cord 

Claude, VHermitte, 1915 . . . 272 

201. Shell explosion: Autopsy — lungs burst! Sencert, 1915 ... 274 

202. Shell explosion: Hemorrhage in spinal canal and bladder Ravaut, 1915 . . . 276 

203. Shell explosion: Hemorrhage and pleocytosis of spinal fluid 

Froment, 1915 . . . 277 

204. Shell explosion: Pleocytosis of spinal fluid Guillain, 1915 . . . 279 

205. Shell explosion: Pleocytosis of spinal fluid as late as a month after 

explosion Souques, Donnet, 1915 . . . 280 

206. Burial: Thecal hemorrhage Leriche, 1915 . . . 282 

207. Shell explosion: Hypertensive spinal fluid Leriche, 1915 . . . 283 

208. Bullet wound: Hematomyelia; partial recovery Mendelssohn, 1916. . .284 

209. Shell explosion, subject prone: Hematomyelia Babinski, 1915 . . . 286 

210. Struck by missile: Hysterical paraplegia? Herpes; segmentary 

symptoms Elliot 1914 . . . 288 



TABLE OF CONTENTS XXV 

Case PAge^ 

211. Mine explosion: Head bruises, labyrinth lesions, canities unilateral 

Lebar, 1915. . .291 

212. Shrapnel wounds: Focal canities; hysterical symptoms. . .Arinstein, 1915. . .292 

213. Burial: Organic (?) hemiplegia Marie, Levy, 1917. . . 293 

214. Shell explosion; no wound: Organic and functional symptoms 

Claude, L'Hermitte, 1915 . . . 294 

215. Gassing: Organic symptoms Neiding, 1917 . . . 296 

216. Gassing: Mutism, battle dreams Wiltshire, 1916. . . 297 

217. Shell explosion: Organic deafness; hysterical speech disorder 

Binswanger, 1915 . . . 298 

218. Distant shell explosion not seen or heard: Tympanic rupture, cere- 

bellar symptoms Pitres, Marchand, 1916 . . . 300 

219. Mine explosion: Organic and functional symptoms Smyly, 191 7. . .302 

220. Shrapnel skull wound: Differential recovery from functional symp- 

toms Binswanger, 1917 . . .303 

221. Shell explosion shrapnel wound: Battle memories, scar hyperesthetic 

Bennati, 19 16. . .305 

222. Shrapnel wounds, operation: Hysterical facial spasm Batten, 191 7. . .306 

223. Shell explosion: Tremors and emotional crises • Myers, 19 16 . . .307 

224. Shell explosion, comrades killed: Tremors, crises .Meige, 1916. . .308 

225. Under fire: Tremophobia: French artist's description Meige, 1916. . .310 

226. Shell explosion: German soldier's account of Shell-shock symptoms 

Gaupp, 1915... 312 

227. A British soldier's account of shell-shock Batten, 1916 . . . 315 

228. Blown up by shell: Crural monoplegia; hysterical four days later Leri, 1915. . .317 

229. Shell explosion nearby: Description of treatment to demonstrate 

hysterical nature of characteristic symptoms Binswanger, 1915 . . .318 

230. Leg wound: Pseudocoxalgic monoplegia and anesthesia 

Roussy, L'Hermitte, 1917. . .323 

231. Leg contusion: Crural monoplegia, hysterical; later crutch paraly- 

sis, organic Babinski, 1917 . . . 324 

232. War strain: Arthritis; crural monoplegia and anesthesia; hysterical 

"conversion hysteria" MacCurdy, 1917 . . . 325 

233. Lance thrust in back; Crural monoplegia Binswanger, 1915 . . . 326 

234. Shell explosion: After six days, crural monoplegia ("metatrau- 

matic" suggesting persisting hypersensitive phase after shell-shock) 

Schuster, 1916. . .329 

235. Wound of foot: Acrocontracture, seven months' duration; psycho- 

electric cure at one sitting Roussy, L'Hermitte, 1917 . . . 330 

236. Shell explosion: Trauma; emotion; hysterical paraplegia. Abrahams, 1915. . -33 2 

237. Shell explosion: Burial; paraplegia Elliot, 1914. . -334 

238. Shell explosion: Paraplegia and sensory symptoms, organic? . .Hurst, 1915 . . . 33s 

239. War strain and rheumatism; no emotional factors: Paraplegia, later 

brachial tremor Binswanger, 1915 . . 336 



XXVI TABLE OF CONTENTS 

Case Page 

240. Emotion in fever patient from watching barrage creep up: Para- 

plegia Mann, 1915 . 

241. Incentives, domestic and medical, to paraplegia Russel, 1917. 

242. Bullet in back: Hysterical bent back; "camptocormia" . . .Souques, 1915, 

243. Shell explosion: Camptocormia Roussy, UHermitte, 1917. 

244. Shell explosion; burial: camptocormia Roussy, UHermitte, 191 7. 

245. Shell explosion; burial; Paraplegia, later camptocormia. . . .Joltrain, 1917. 

246. Bulletin thigh: Astasia-abasia. Wound of neck: Again astasia-abasia 

Roussy, UHermitte, 191 7 

247. Shell explosion : Wound of thorax; astasia-abasia 

Roussy, UHermitte, 191 7 

248. War strain and fall in trench without trauma: Dysbasia. . . .Nonne, 191 5 

249. Shell explosion: Partial burial; hysterical symptoms in parts buried 

Arinstein, 1916. 

250. Wound of hand: Acroparalysis Roussy, UHermitte, 1917, 

251. Wound of arm: Hysterical paralysis Chattier 1915 

252. Wound in brachial plexus region: Supinator longus contracture 

Leri, Roger, 191 5 . 

253. Contusion of muscle with "stupef active" paralysis of biceps (supi- 

nator longus still functioning) Tinel, 1917 . 

254. Wound of arm: Blockage of impulses to hand movements . . . Tubby, 1915 . 

255. Shell explosion: Bilateral symmetrical phenomena Gerver, 1915. 

256. Shell explosion: Paralytic symptoms on side exposed: Contra- 

lateral irritative symptoms Oppenheim, 1915 

257. Shell explosion: Bilateral asymmetrical symptoms Gerver, 1915. 

258. Shell explosion: Se nsory disorder on side exposed Gerver, 1915 . 

259. Shell explosion: Hysterical deafness and other symptoms; relapse 

Gaupp, 1915 

260. Shell explosion: Deafness Marriage, 1917 

261. Mine explosion: Deaf mutism; recovery on epistaxis and fever 

Liebault, 19 16. 

262. Shell explosion: Deafmutism Mott, 1916 . 

263. Shell explosion: Deafmutism and convulsions Myers, 1916. 

264. Gunfire: Aphonia Blassig, 1915 , 

265. Shell-shock mutism: (a), observed, (b) dreamed of, (c), developed 

by victim of shell explosion Mann, 1915 

266. Mortar explosion: Deafness Lattes, Goria, 191 7. 

267. Shell-explosion: onomatopoeic noises Ballet, 1914. 

268. Shell explosion: Gravel in eyes; eye and face symptoms. .Ginestous, 1916. 

269. Shell explosion; burial; blow on occiput; Blindness Greenlees, 1916. 

270. Shell-shock amblyopia: Composite data Parsons, 1915 . 

271. Factors in shell-shock amblyopia: Excitement, blinding flashes, fear, 

disgust, fatigue Pemberton, 1915 

272. Shell explosion amblyopia Myers, 1915 



TABLE OF CONTENTS XXVll 

Case Page 

273. Shell windage without explosion: Cranial nerve disorder .Pachantoni, 191 7 . . . 378 

274. Initial case in Babinski's series to show chloroform elective exagger- 

ation of reflexes Babinski, Froment, 191 7 . . . 380 

275. Wound of ankle: Contracture, chloroform effect 

Babinski, Froment, 191 7. . .383 

276. "Reflex" disorder of right leg: Chloroform effect 

Babinski, Froment, 191 7. . .384 

277. Bullet in calf: Hysterical lameness cured — reflex disorder asso- 

ciated therewith not cured Vincent, 1916 . . .385 

278. Trauma of foot: Hysterical dysbasia and reflex disorders; differ- 

ential disappearance of hysterical symptoms Vincent, 191 7 . . . 386 

279. Shell-shock and paraplegia: Vasomotor and secretory disorder 

twenty months later Roussy, 1917 . . . 387 

280. Tetanus clinically cured: Phenomena reproduced under chloro- 

form anesthesia Monier-Vinard, 1917 . . . 388 

281. Example of a "reflex" disorder after shell explosion at great distance 

F err and, 191 7. . .390 

282. Shell fire: Shell-shock symptoms delayed McW alter, 1916. . .391 

283. Shell-shock symptoms early and late Smyly, 1917 . . . 392 

284. Wounds: Gassing; burial; collapse on home leave Elliot Smith, 1916. . .393 

285. Late sympathetic nerve effect after bullet wound of neck. . . . Tubby, 1915 . . .394 

286. Hysterical crural monoplegia after fall from horse under fire (reminis- 

cence of similar ante bellum accident) Forsyth, 1915 . . . 395 

287. Shell explosion, cave-in: Right leg symptoms {ante bellum experiences) 

Myers, 1916 . . . 396 

288. Shell explosion, wound of back: Paraparesis (subject always weak in 

legs) Dejerine, 1915 . . . 397 

289. Wound near heart: Fear; paraparesis (subject always weak in legs) 

Dejerine, 191 5. . .399 

290. Wounds: Tic on walking and recovery except frontalis tic (empha- 

sis of ante bellum habit) Westphal, Hiibner, 1915 . . .401 

291. Fatigue and emotion: Hysterical hemiplegia (similar hemiplegia ante 

bellum) Roussy, L'Hermitte, 1917 . . . 402 

292. War strain: Hemiplegia (similar hemiplegia ante bellum, subject's 

father hemiplegic) Dupres, Rist, 1914 . . . 403 

293. Shell explosion and burial: Deaf mutism (speech difficulty ante 

bellum) MacCurdy, 1917 . . .405 

294. War strain: Shell-shock and psychotic symptoms determined to 

parts ante bellum Zanger, 1915 . . . 406 

295. Mine explosion: Emotion; delirium (previous head trauma without 

unconsciousness) Lattes, Goria, 1917. . .407 

296. Sniper stricken blind in shooting eye Eder, 1916. . .408 

297. Anticipation of warfare: Fall while mounting sentry; hysterical 

blindness Forsyth, 1915 . . . 408 



XXV111 TABLE OF CONTENTS 

Case Page 

298. Spasmodic neurosis from bareback riding (similar episode ante 

helium) Schuster, 1914 . . . 409 

299. Ante bellum spasm of hands Hewat, 1917 . . . 409 

300. Quarrel: Hysterical chorea, reminiscent of former attack and itself 

reminiscent of organic chorea in subject's mother Dupuoy, 1915 ... 411 

301. Hallucinations and delusions of ante bellum origin: Treatment by- 

explanation Rows, 1916 ... 412 

302. Tremors and convulsive crises in a poor risk Rogues de Fursac, 1915 . . . 413 

303. Emotionality and tachycardia in a martial misfit Bennati, 1916 . . . 415 

304. Hereditary instability Wolfsohn, 1918 . . . 416 

305. Genealogical tree of a shoemaker Wolfsohn, 1918 ... 417 

306. Traumatic hysteria without hereditary or acquired psychopathic 

tendency Donath, 1915 . . . 418 

307. Mine explosion, burial: Neurosis in perfectly normal soldier 

MacCurdy, 1917. . .419 

308. Shell explosion: Tremophobia Meige, 1916 ... 421 

309. Frozen in bog: Glossolabial hemispasm Binswanger, 1915 . . .424 

310. Bruise by horse: Invincible pain — subject cured by performing 

heroic feat Loewy, 1915 . . . 426 

311. Kick by horse: Hysterical symptoms including monocular diplopia 

Oppenheim, 1915. . .427 

312. Windage from non-exploding shell: Emotion; homonymous hemian- 

opsia Steiner, 1915 . . . 428 

313. Shell-shock psoriasis Gaucher, Klein, 1916. . .429 

314. Croix de guerre and Shell-shock got simultaneously: Hallucinatory 

bell-ringing reminiscent of civilian work 

Laignel-Lavastine, Courbon, 1916. . .430 

315. Waked by shell explosion: Nystagmiform tremor (occupational 

reminiscence in cinema worker) and tachycardia Tinel, 19 15. . .432 

316. Synesthesialgia: Foot pain on rubbing dry hands 

Lortat-Jacob, Sezary, 1915. . .433 

317. Shell-shock and burial: Clonic spasms, later stupor Gaupp, 1915 . . .435 

318. War stress (liquid fire) and shell-shock: Puerilism 

Charon, Halberstadt, 1916. . .437 

319. Bombed from aeroplane: Battle dreams; dizziness; fugue 

Lattes, Goria, 191 7. . .439 

320. Hyperthyroidism after box drops from aeroplane Bennati, 1916. . .440 

321. Shell dropped without bursting: Stupor and delirium. .Lattes, Goria, 1917. . .441 

322. Subject carrying explosives is jostled: Unconsciousness, deafmutism, 

later camptocormia Lattes, Goria, 1917 . . . 443 

323. Grazed by sliding cannon: Stupor and amnesia Lattes, Goria, 191 7. . .444 

324. Shell explosions nearby: Emotion and insomnia Wiltshire, 1916. . .445 

325. Shell explosion: symptoms after hearing artillery twelve days later 

Wiltshire, 1916. . .446 



TABLE OF CONTENTS XXIX 

Case PaGe 

326. Exhaustion (heat?): Hyperthyroidism, hemiplegia Oppenheitn, 1915. . .44^ 

327. War strain and rheumatism: tremors Binswanger, 1915 . . .448 

328. Shell explosion; emotion: Fear and dreams Mott, 1916. . .451 

329. Under fire; barbed wire work: tremors and sensory symptoms 

Myers, 1916. . .452 

330. Shell explosion: Emotional crises; twice recurrent mutism 

Mairet, Pier on, Bouzansky, 1915. . .453 

331. Shell explosion: Emotional crises (fright at a frog) 

Claude, Dide, Lejonne, 19 16. . .455 

332. War strain; wound; burials; shell-shock: neurosis with anxiety and 

dreams: Relapse MacCurdy, 1917. . .457 

333. Bombed by airplane: Suicidal thoughts; oniric delirium; "moving 

picture in the head" Hoven, 1917. . .460 

334. Shell explosion; emotion at death of best friend: Stupor and amnesia 

Gaupp, 1915. ..462 

335. Emotional shock from shooting comrade: Horror, sweat, stammer, 

nightmare Rows, 1916. . .463 

336. Emotion at death of comrade: Phobias Bennati, 1916. . .464 

337. Shell explosion: Fright; delayed loss of consciousness Wiltshire, 1916. . .465 

338. Shell explosion; burial work: amnesia; unpleasant ideas reflexly 

conditioned by shell whistling Wiltshire, 1916. . .467 

339. Comrade's death witnessed: Suicidal depression Steiner, 19 15 . . .468 

340. Marching and battles: Neurasthenia? Bonhoefer, 19 15 . . .469 

341. English schoolmaster's account of dreams Mott, 1918. . .470 

342. War dreams shifting to sex dreams Rows, 1916 . . . 472 

343. Shock at death of comrade: War and peace dreams Rows, 1916. . .474 

344. War dreams including hunger and thirst Mott, 19 18. . .475 

345. Burial work: Olfactory dreams and vomiting Wiltshire, 1916. . .476 

346. War dreams: Phobia conditioned on postoniric suggestion. .Duprat, 191 7. . .477 

347. Service in rear: War dreams not based on actual experiences 

Gerver, 1915. . .478 

348. Hysterical astasia-abasia: Heterosuggestive "big belly" 

Roussy, Boisseau, Cornil, 191 7. . .479 

349. Collapse going over the top: Neurasthenia Jolly, 1916. . .481 

350. Battles: Mania and confusion Gerver, 1915 . . .483 

351. Machine-gun battle: Mania and hallucinations Gerver, 1915 . . .484 

352. Attacks and counter-attacks: Incoherence and quick development of 

scenic war hallucinations Gerver, 1915 . . . 485 

353. Hysterical stupor under shell fire after 2 days in the trenches 

Gaupp, 1915. ..486 

354. Monosymptomatic amnesia Mallet, 1917 . . . 488 

355. Aviator shot down: Mental symptoms, organic MacCurdy, 191 7. . .489 

356. Shell fire and corpse work: Daze with relapse; mutism Mann, 1915 . . . 491 

357. Mine explosion: Confusion Wiltshire, 1916 . . . 492 



XXX TABLE OF CONTENTS 

Case 

358. Shell explosion: Alternation of personality Gaupp, 1915 

359. "A Horse in the Unconscious" Eder, 1916 

360. Shell explosion, gassing, fatigue: Anesthesia Myers, 1916 

361. Shell explosion and burial: Somnambulism; dissolution of amnesia 

under hypnosis Myers, 1915 

362. Shell explosion with injuries: Somnambulism Donath, 1915 

363. Shock: Stupor as if dead Regis, 1915 

364. Emotions over battle scenes : Twenty-four days' somnambulism 

Milian, 19 15 

365. Putative loss of brother in battle: Somnambulism and mutism 

twenty-seven days Milian, 1915 

366. Shell explosion: Trauma, windage: Somnambulism four days 

Milian, 19 15 

367. Burial, head trauma; gassing: Tremors, convulsions, confusion, fugue 

Consiglio, 19 16 

368. Shell explosion: Hysterical symptoms and tendency to fugue 

Binswanger, 19 15 

369. Burial: Dissociation of personality Feiling, 1915 

370. Ear Complications and hysteria Buscaino, Coppola, 1916 

SECTION C. SHELL-SHOCK DIAGNOSIS 

371. Value of lumbar puncture Souques, Bonnet, 1915 

372. Meningeal and intraspinal hemorrhage: Lumbar puncture. .Guillain, 19 15 

373. Burial: Slight hyperalbuminosis Ravaut, 1915 

374. Paraplegia, organic: Lumbar puncture Joubert, 19 15 

375. Gunshot of spine: Spinal concussion, quadriplegia, cerebellospasmodic 

disorder Claude, L'Hermitte, 191 7 

376. Trauma of spine: Anesthesia and contracture, homolateral, with 

trauma Oppenheim, 1915 

377. Mine explosion combining hysterical and lesional effects. . .Dupouy, 1915 

378. Shell explosion: Hysterical and organic symptoms Hurst, 1917 

379. Gunshot: Cauda equina symptoms, combined with functional 

paraplegia Oppenheim, 1915 

380. Intraspinal lesion: Persistent anesthesia Buzzard, 19 16 

381. Functional shell-shock: Erroneous diagnosis Buzzard, 19 16 

382. Retention of urine after shell-shock Guillain, Bane, 1917 

383. Same Guillain, Barre, 1917 

384. Incontinence of urine after shell-shock and burial 

Guillain, Barre, 191 7 

385. Struck by missile: Crural monoplegia; plantar reflex absent 

Paulian, 1915 

386. Shell explosion: Crural monoplegia; sciatica (neuritis?) Souques, 19 15 

387. Functional paraplegia and internal popliteal neuritis Roussy, 19 15 

388. Bullet in hip: Local "stupor" of leg Sebileau, 1914 



TABLE OF CONTENTS XXXI 

Case Page 

389. Localized catalepsy: Hysterotraumatic Sollier, 19 17 . . .-344 

390. Contracture: Hysterotraumatic Sollier, 191 7 . . . 545 

391. Crural monoplegia, tetanic: Recovery Routier, 1915 . . . 546 

392. Spasms, contracture, crises — tetanic Meriel, 1916 . . . 548 

393. Shell explosion, windage, flaccid paraplegia, not "spinal contusion" 

Leri, 1915. ..550 

394. Scalp wound: Quadriparesis; paraplegia, cataleptic rigidity of anes- 
thetic legs Clarke, 1916 ... 551 

395. Shell explosion: Spasmodic contractions of sartorii, persistent in 
sleep Myers, 1916. . .553 

396. Shell explosion: Brown-Sequard's syndrome, hematomyelic? . . Ballet, 1915 . . . 555 

397. Question of structural injury of spinal cord Smyly, 19 17 . . . 557 

398. Dysbasia, psychogenic round an organic nucleus (cerebellar?) 

Cassirer, 19 1 6. . .557 

399. Shell explosion: Dysbasia, in part hysterical, in part organic? 

Hurst, 1915...558 

400. Peculiar walking tic Chavigny, 1917 . . . 559 

401. Mine explosion: Camptocormia. Hospital rounder twenty months — 
cure by electrotherapy, 1 hour 

Marie, Meige, Behagne, Souques, Megevand, 191 7. . .561 

402. Astasia-abasia Guillain, Bane, 1916 . . . 563 

403. Shell wounds: Abdominothoracic contracture, tetanic, four months 
after injury Marie, 1916 . . . 564 

404. Shoulder dislocation: Hysterical paralysis of arm Walther, 1914. . .566 

405. Gunshot: Paralysis of arm increasing in degree Oppenheim, 1915 . . . 567 

406. Wound of wrist: Differential glove anesthesias Romner, 191 5 . . . 568 

407. Hysterical contracture combined with edema and vasomotor dis- 
order Ballet, 1915 . . . 569 

408. Hemiparesis with syringomyelic dissociation of sensations: Hem- 
atomyelia? Ravaut, 1915 ... 570 

409. Brachial monoplegia: Tetanic Routier, 1915 . . . 571 

410. Paralysis of right leg: Hysterical? Organic? "Microorganic"? 

Von Sarbo, 1915 . . . 572 

411. Shell explosion: Burial: Paralysis on third day 

Leri, Froment, Mahar, 19 15 . . . 573 

412. Shell explosion: Hemiplegia. Plantar areflexia Dejerine, 1915 . . . 575 

413. Shell explosion: Tic versus spasm Meige, 1916 . . . 577 

414. Shell explosion: Tremors, anaesthesias Mott, 1916 . . . 580 

415. Hysteria, appendix to trauma MacCurdy, 191 7 . . . 582 

416. Peripheral nerve injury: Neurasthenic hyperalgesia Weygandt, 191 5. . .583 

417. Soldier lead worker: Peripheral neuritis Shufflebotham, 1915 . . . 584 

418. "Peripheral neuritis" cured by faradism Car gill, 1916. . . 585 

419. Late tetanus Bouquet, 1916 . . . 586 

420. Spasmodic neurosis and neurasthenia . . '. Oppenheim, 191 5 . . . 588 



XXX11 TABLE OF CONTENTS 

Case Page 

421. Hysterical and reflex ("physiopathic") disorders Babinski, 1916. . .590 

422. Bullet wound: Paralysis non-" organic," non-hysterical, i.e. reflex 

Babinski, Froment, 191 7. . .592 

423. Asymmetry of reflexes under chloroform Babinski, Froment, 191 7. . .594 

424. Reflexes under chloroform Babinski, Froment, 19 15 . . .595 

425. Same Babinski, Froment, 1915 . . . 596 

426. Shrapnel wound: Monoplegia, hysterical and organic 

Babinski, Froment, 1917. . .597 

427. Gunshot, later Erb's palsy: "reflex"? Oppenheim, 1915 . . . 598 

428. Paralysis hysterical? Organic? Gougerot, Charpentier, 1916. . .600 

429. Same Gougerot, Charpentier, 1916 . . . 602 

430. Same Gougerot, Charpentier, 1916 . . . 604 

431.} 

rReflex "paralysis" Delherm, 1916 . . . 606 

433. Shell explosion: Functional blindness, monosymptomatic . . .Crouzon, 1915 . . .609 

434. Retrobulbar neuritis (nitrophenol) Sollier, Jousset, 1917. . .611 

435. Eye symptoms, hysterical Westphal, 1915 . . . 613 

436. Sandbag on head: Eye symptoms: Lenses Harwood, 1916. . .615 

437. Hemianopsia, organic or functional? Steiner, 1915 . . . 616 

438. Hysterical pseudoptosis Laignel-Lavastine, Ballet, 1916. . .617 

439. Shell explosion: Rombergism Beck, 1915 . . . 620 

440. Case for otologists and neurologists Roussy, Boisseau, 191 7. . .622 

441. Jacksonian syndrome: Hysterical Jeanselme, Huet, 1915 . . .625 

442. Leg tic: Phobia against crabs Duprat, 1917 . . . 627 

443. Convulsions reminiscent of fright Duprat, 1917 . . . 628 

444. Fatigue, delusions, fugue Mallet, 1917 . . . 629 

445. Obsessions and fugue Mallet, 1917 . . . 631 

446. Aprosexia and birdlike movements Chavigny, 1915 . . . 632 

447. Shell explosion: Unconsciousness (45 days): Mutism LUbault, 1916. . .633 

448. Shell explosion: Recurrent amnesia Mairet, Pieron, 191 7. . .634 

449. Shell explosion: Comrade killed: Amnesia Gaupp, 1915. . .635 

450. Shell explosion: Recurrent amnesia Mairet, Pieron, 1915 . . . 636 

451. Soldiers' heart, neurotic and organic MacCurdy, 191 7. . .639 

452. Soldiers' heart, neurotic MacCurdy, 1917 . . . 640 

453. Shell explosion: Hysteria: Malingering (?) Myers, 1916. . .642 

454. Officer who could not kick Mills, 1917 . . . 644 

455. "Simulation": Diagnosis incorrect Voss, 1916. . .645 

456. Wound: Hysterical edema? Lebar, 1915 . . . 646 

457. Head trauma: simulation? Hysteria? Surgical? Voss, 1916 . . . 648 

458. Disease and disorder to avoid service Collie, 1916 . . . 649 

459. Yes-No test in anesthesia Mills, 1917 . . . 651 

460. Guardhouse test Roussy, 1915 . . . 651 

461. Light in a dark room Briand, Kalt, 1917 . . . 652 

462. Mutism simulated Sicard, 1915 . . . 654 



TABLE OF CONTENTS 



XXX111 



Case 

463. Deafmutism simulated Myers, 1916 

464. Same: Explained by patient Myers, 1916 

465. Deafmutism: Appearance of malingering Gradenigo, 1917 

466. A lame rascal Gilles, 1917 

467. Picric acid jaundice Briand, Haury, 1916 

468. Swelling of hand and arm, 7 months Leri, Roger, 19 15 

469. Shell-shy German Gaupp, 1915 

470. Germany sends back a simulator Marie, 1915 

471. Simulation of Quincke's disease Lewitus, 1915 

472. "Pensionitis" Collie, 1915 

SECTION D. SHELL-SHOCK TREATMENT AND RESULTS 



Page 
•455 
..657 
..658 

..659 
..660 
..663 
..664 
..664 
..665 
..666 



473- 
474- 
475- 
476. 
477- 
478. 
479- 
480. 
481. 
482. 

483. 
484. 
485. 
486. 
487. 
488. 

489. 
490. 
491. 
492. 
493- 
494- 

495- 
496. 

497- 
498. 
499. 
500. 
Soi. 
502. 



Deafmutism: Spontaneous cure .Mott, 

Two returns to the front Gilles, 

Vicissitudes in 15 months Purser, 

Deafmutism: Spontaneous cure Jones, 

Course of an oniric delirium Buscaino, Coppola, 

Same Buscaino, Coppola, 

Paraplegia: Cure by Iron Cross Nonne, 

Mutism cured by getting drunk Proctor, 

Mutism cured by working in vineyard Anon, 

Deafmutism: Spontaneous recovery of speech. Recovery of hear- 
ing by isolation Zanger, 

Excess of sympathy on furlough Binswanger, 

Hysterical seizures treated by hydrotherapy Hirsckfeld, 

Low blood pressure treated by pituitrin Green, 

Manual contracture: Various treatments Duvernay, 

Massage and mechanotherapy Sollier, 

Mine explosion; headache: Lumbar puncture Ravaut, 

Hysterical clenched fist: Treatment by fatigue of flexors Reeve, 

Hysterical adduction of arm: Treatment by induced fatigue. .Reeve, 

Hysterical cross-legs: Treatment by induced fatigue Reeve, 

Hysterical torticollis: Treatment by induced fatigue Reeve, 

Claw foot (2 years): Cure by induced fatigue Reeve, 

Traumatic and post-traumatic effects: Surgical treatment 

Binswanger, 

Vomiting: Cure by restoration of self-confidence McDowell, 

Self-accusatory delusions: Treatment by "autognosis" Brown, 



1916. . 
1916. . 
1917.. 
1915.. 
1916. . 
1916. . 
1915.. 
1915.. 
1916. . 

1915.. 
1915.. 
1915.. 
1917.. 
1915.. 
1916. . 
1915.. 
1917.. 
1917.. 
1917.. 
1917.. 
1917.. 

1917.. 
1917.. 
1916. . 



672 

675 
676 
678 
679 
681 
682 
682 
683 

684 
685 
688 
690 
691 
692 

693 
694 

695 
696 
697 
698 

699 
701 

702 



Deafmutism in three men shell-shocked at one time Roussy, 1915 . . . 703 

Vomiting; incontinence, abasia: Cure by persuasion. . .McDowell, 1916.705-706 

Hysterical convulsions cured by an explanation Hurst, 1917 . . . 706 

Course of a case with crises of trembling Roussy, 1915 . . . 706 



xxxiv 



TABLE OF CONTENTS 



Case 
503. 
504. 
505- 

506. 

507- 
508. 

5°9- 
510. 

Sii- 

512. 

513- 
514- 



Page 
Two cases of lameness cured by persuasion Russel, 191 7 . . . 707 



Head trauma: Treatments by bandage, isolation, open air and to- 
and-fro transfers Binswanger, 1915 . 

Rationalization of war memories , , Rivers, 1918 . 

Same .Rivers, 1918 . 

Same ,, ... Rivers, 1918 . 

Same ,„.... Rivers, 1918 . 

Same, without redeeming feature as nucleus of rationalization 

Rivers, 19 18. 

Paraplegia cured by removal of crutches , Veale, 191 7 . 

Same , Veale, 1917 . 

Paraplegia: Chocolates versus isolation , . ., Buzzard, 1916. 

Blindness, mutism, deafness. Immediate spontaneous recovery 
from the first; gradual recovery from second; deafness cured by 
" small operation " Hurst, 1917 . 

515. Deafness: Treatment by stimulating vestibular apparatus . O'Malley, 1916. 

516. Mutism: Treatment by operative manipulation Morestin, 1915. 

517. Visual impairment: Treatment by suggestion, faradism injections 

Mills, 1915. 

518. Aphonia: Treatment by manipulation in larynx O'Malley, 1916. 

519. Same Vlasto, 1917 . 

520. Mutism, amnesia: Treatment by faradism; climatic cure in dream 

Smyly, 191 7. 

521. Blindness: Cure by injections in temple Bruce, 1916. 

522. Deafness cured by suggestion in writing Buscaino, 1916. 

523. Reproduction of Shell-shock story in hypnosis: Recovery. . . .Myers, 1916. 

524. Same Myers, 1916 . 

525. Automatism, amnesia, deafmutism: Recovery by hypnosis.. .Myers, 1916. 

526. Mutism: Recovery by hypnosis Hurst, 1917 . 

527. Stammering: Cure by hypnosis Hurst, 1917 . 

528. Mutism and amnesia: Cure by hypnosis Myers, 1916 . 

529. Victoria Cross winner: Bayonet clutch contracture revealed by hyp- 

nosis Eder, 1916 . 

530. Contracture: Hypnotic cure "indecently quick" Nonne, 1915. 

531. "Doll's head" anesthesia: Mutism: Cure by hypnosis Nonne, 1915 . 

532. Mine explosion: Tremors (also ante helium tremors): Cure by hyp- 

nosis Griinbaum, 1916 . 

533. Astasia-abasia: Cure by hypnosis Nonne, 1915. 

534. Crural monoplegia: Cure by hypnosis Hurst, 191 7 . 

535. Tremors and sensory disorders: Cure by hypnosis Nonne, 1915 . 

536. Paraplegia of gradual development: Cure by repeated hypnosis 

Nonne, 1915. 

537. Visual impairment and dysbasia: Cure by hypnosis Ormond, 1915. 



708 
712 
7i3 
7i4 
7i5 

716 

717 
718 
719 



.720 
.721 
.722 

.724 

.725 
.727 

.728 
.729 

• 73o 

• 732 
■733 

734 
736 
737 
739 

74i 

742 

744 

745 
747 
748 
749 

75i 

752 



TABLE OF CONTENTS 



XXXV 



Case 

538. 

539- 

540. 

54i. 

542. 
543- 
544- 

545- 
546. 

547- 

548. 
549- 
55o. 
55i. 

552. 

553. 
554- 

555- 

556. 
557.. 
558. 
559- 



Blindness cured by hypnosis Hurst, 1916 

Postoperative retention of urine: Relief by hypnosis Podiapolsky, 191 7 

Postoperative pains: Relief by hypnosis Podiapolsky, 191 7 

Stereotyped war dream and ante helium headache: Cure by hypnosis 

Riggall, 191 7 
Amnesia and ante helium headache: Cure by hypnosis. ..Burmiston, 191 7 

Convulsions cured by hypnosis Hurst, 1917 

Two attacks of mutism: Spontaneous recovery from one in 18 

months, from the other by hypnosis Eder, 1916 

Neurasthenic symptoms cured by repeated hypnosis Tombleson, 191 7 

Neurasthenic symptoms: Improvement under repeated hypnosis 

Tombleson, 191 7 
Convulsions "Jacksonian" and dysbasia: Cure by hypnosis 

Tombleson, 191 7 

Agoraphobia: Cure by hypnosis Hurst, 1917 

Manual tremors: Treatment by forcing and isolation. . .Binswanger, 19 15 

Mutism: Psychoelectric cure Scholz, 1915 

Hemiplegia and deaf mutism; (also convulsions by heterosuggestion) : 

Improvement by faradism; full recovery by suggestion. A rinstein, 19 15 
Deafmutism, cures, relapses and eventual cure by anesthesia 

Dawson, 191 6 

Deafness: Cure by suggestion on emerging from ether Bruce, 1916 

Aphasia, hemiplegia, hemianesthesia, and (by medical suggestion) 

trismus: Cure by anesthesia and suggestion Arinstein, 191 5 

Triplegia, mutism, jumping- jack reactions: Cure by anesthesia, 

verbal suggestion, faradism Arinstein, 1915 

Mutism and musical alexia: Cure by anesthesia Proctor, 191 5 

Deafmutism: Deafness cured by anesthesia Gradenigo, 191 7 

Interaction of two cases (deafmute and mute) under treatment 

Smyly, 191 7. 



P^-GE 

753 
754 
755 

756 
757 
759 

759 
760 

761 

762 
763 
764 
766 

767 

768 
770 

771 

773 
775 
776 

777 



560. Dysbasia: Cure by stovaine anesthesia Claude, 1917. . . 778 

561. Same Claude, 1917. . . 779 

562. Deafmutism Bellin, Vernet, 191 7 . . . 780 

563. Monoplegia: Cure by electricity administered with a bored and 

authoritative look Adrian, Yealland, 1917 . . . 782 

564. Monoplegia after sling: Technique of electrical suggestion and 

"rapid" reeducation Adrian, Yealland, 1917. . . 783 

565. Hysterical "sciatica": Treatment by faradism and verbal suggestion 

Harris, 1915. . .785 

566. Prognosis of intensive reeducation in reflex (physiopathic) disorder 

Vincent, 191 6. . .786 

567. Hysterical contracture (with physiopathic features) brutally con- 

quered Ferrand, 1917. . . 788 



XXXVI TABLE OF CONTENTS 

Case Page 

568. Paraparesis: Cure by exercises electrically provoked Turrell, 1915. . . 790 

569. Astasia-abasia: ("Lourdes-like" cure) Voss, 1916. . . 791 

570. Abasia: Rapid cure Schultze, 1916. . . 792 

571. Heterosuggestive brachial paresis: Electric suggestion and recovery 

in five days Hewat, 1917 . . . 794 

572. Contracture of right index finger and thumb: Psychoelectric cure 

Roussy, UHermitte, 191 7. . .795 

573. Brachial monoplegic able to descend ladder with arms only. . . Claude, 1916 ... 795 

574. Brachial monoparesis: Vicissitudes of treatment Vincent, 1917 . . . 796 

575. Paresis and sensory disorder: Reeducation Binswanger, 1915 . . . 798 

576. Seizures (of ante helium origin), astasia-abasia, anesthesias: Reedu- 

cation Binswanger, 1915 . . . 800 

577. Progress in case of paresis of foot and spasticity of hip. . Binswanger, 1915. . .805 

578. Mutism (Reeducation) Briand, Philippe, 1916. . . 808 

579. Stammering: Isolation and reeducation Binswanger, 1915 . . . 810 

580. Deafmutism: Phonetic reeducation Liebault, 1916 . . . 814 

581. Aphonia: Pressure on sternum and respiratory gymnastics Garel, 1916 . . .816 

582. Stammering: Reeducation MacMahon, 1917. . . 817 

583. Speech disorder: Reeducation MacMahon, 1917 . . . 818 

584. Camptocormia: Psycho-electric cure: lameness cured by reeducation 

Roussy, UHermitte, 191 7. . .819 

585. Deafmutism: Speech recovery by suggestion and reeducation: Hear- 

ing by reeducation Liebault, 1916 ... 822 

586. Mutism; stammering; Reeducation; hypnosis MacCurdy, 1917. . .823 

587. Anesthesias: Spontaneous gradual recovery: "Paralysis" cured 

by reeducation Binswanger, 1915 . . . 824 

588. Deafmutism; head movements, anesthesia: Cure by faradism, mas- 

sage and reeducation k Arinstein, 1916 . . . 827 

589. Amnesia and paralysis: Reeducation Batten, 1916. . .828 

SECTION E. EPICRISIS 

paragraph 

Terminology 1-8 

Diagnostic Delimitation Problem 9-39 

The Nature of War Neuroses 40-74 

Diagnostic Differentiation Problem 75~99 

General Nature of Shell-shock 89-102 

Treatment: General Observations 103-114 



La divina giustizia di qua punge 
quell' Attila che fu flagello in terra. 

Divine justice here torments that Attila, who 
was a scourge on earth. 

Inferno, Canto xii, 133-134. 



A. PSYCHOSES INCIDENTAL IN THE WAR 

The data from all the belligerent countries, collected in 
this book, go far to prove that, whatever at last you elect 
to term Shell-shock, you must pause to consider whether your 
putative case is not actually: 

A matter of spirochetes? 

The response of a subnormal soldier? 

An equivalent of epilepsy? 

An alcoholic situation? 

A result of neurones actually hors de combat ? 

A state of bodily weakness (perhaps of faiblesse irritable) ? 

A bit of dementia praecox? 

One of the ups and downs of the emotional (affective, 
cyclothymic) psychoses? 

An odd psychopathic reaction in which the response is 
abnormal not so much by reason of excessive stimulus as 
by reason of defective power of response? 

On a simpler basis, is not our Shell-shocker just a banal 
example of hysteria, neurasthenia, psychasthenia; and is not 
this psychoneurotic more peculiar in his capacity to be 
shocked than are the conditions that purvey the shocks? 

Put more concretely in the terms of available tests and 
criteria, open to the psychiatrist, does not every putative 
Shell-shock soldier deserve at some stage a blood test for 
syphilis? Should we not be reasonably sure we are not fac- 
ing a man inadequate to start with, so far as mental tests 
avail? Should we not verify (even at considerable expense 
of time and money by so-called "social service" methods) 
the facts of epilepsy and epileptic taint? Of alcoholism? 
And so on? There can be no two answers to these questions. 

Upon the following page is a practical grouping of mental 
diseases, devised in the first place, not for war psychoses, but 
for the initial sifting of psychopathic hospital cases. Now 



2 PSYCHOSES 

the psychopathic hospital group of cases constitutes in peace 
practice the closest analogue of the mental cases met in active 
military practice, because the "incipient, acute, and curable"* 
cases, for which psychopathic hospitals are built and which 
flock to or are sent to the wards and outdoor departments of 
such hospitals, are precisely the cases that early come forward 
in active military practice. They are precisely the cases in 
which that pathological event — whatever it is — we know 
as Shell-shock may be expected to develop. It is precisely 
the "incipient, acute, and curable " instances of mental 
disease which we hope to exclude from our American army by 
cis- Atlantic winnowing-out at the hands of neuropsychiatric 
experts — the best preventive we hope both of Shell-shock 
and of other worse mental conditions, if such there be. Mili- 
tary mental practice plainly deals, not so much with frank and 
committable insanity, as with mental diseases of a medically 
milder but a militarily far more insidious nature. 

A further inspection of this grouping of mental diseases 
shows not only that it contains many conditions not usually 
termed "insanity " (such as, e.g., feeblemindedness, epilepsy, 
alcoholism, sundry somatic diseases, psychoneuroses) , but 
that these conditions are presented for practical purposes in 
a certain seemingly arbitrary order. Without attempting 
to justify this selection of scope (not too wide for modern 
psychiatry, most would readily acknowledge), I shall draw 
out a little further what I consider to be the virtues of the 
order selected. In the first place, all will concede, some order 
of consideration of collected data is a prime necessity to the 
tyro. Without an order of consideration the diagnostic tyro 
is but too apt to find in the best textbooks of psychiatry 
(even more easily the better the textbook) all he needs to 
prove that the case in hand is — almost anything he selects 
to make his case conform to! And how much more danger- 
ous this debating-society method of diagnosis (by choice of 
a side and matching a textbook type) may become in the fluid 
and elastic conditions of psychopathic hospital practice, can 

* Official phrase for the scope of the Psychopathic Hospital, 
Boston, Massachusetts. 



PSYCHOSES 



PRACTICAL GROUPING OF MENTAL DISEASES 

The order adopted for these groups (which roughly correspond to botani- 
cal or zoological orders) is a pragmatic order for successive exclusion on the 
basis of available tests, criteria, or information: the actual diagnosis is a 
product of still further differentiation within the several groups. 

The case-histories of this book will show that 

(a) most shell-shock is in group X, Psychoneuroses, 

(b) the diagnostic delimitation problem is chiefly against I. Syphilo- 
psychoses, III. Epileptoses, VI. Somatopsychoses, 

(c) the finer differentiation problem is between X. Psychoneuroses and 
V. Encephalopsychoses. (See Epicrisis, propositions 9-12, 40-43, 72-73.) 

I. Syphilitic Psychoses SYPHILOPSYCHOSES 

II. Feeblemindedness HYPOPHRENOSES 

III. Epilepsy EPILEPTOSES 

IV. Alcoholic, Drug, and Poison 

Psychoses PHARMACOPSYCHOSES 

V. Focal Brain Lesion Psychoses. ENCEPHALOPSYCHOSES 

VI. Symptomatic (Somatic) Psy- 
choses SOMATOPSYCHOSES 

VII. Presenile-Senile Psychoses GERIOPSYCHOSES 

VIII. Dementia Praecox and Allied 

Psychoses SCHIZOPHRENOSES 

IX. Manic-Depressive and Allied 

Psychoses CYCLOTHYMOSES 

X. Psychoneuroses PSYCHONEUROSES 

XI. Other Forms of Psychopathia PSYCHO PATHOSES 



Chart i 



4 PSYCHOSES 

readily be observed by one who contemplates the formes 
frustes and entity-sketches that the "incipient, acute, and 
curable " group of cases presents. 

No conclusions are intended to be drawn in these introduc- 
tory pages. Such conclusions as are risked are placed in the 
Epicrisis (see Section E). But so much can be said: If 
we are ever to surround the problem of Shell-shock (intra 
helium or post helium) , we must approach it with no artificial 
and a priori limitations of its scope. We must not even 
agree beforehand that Shell-shock is nothing but psycho- 
neurosis: that would be a deductive decision unworthy of 
modern science. In the collection of these cases, I have tried 
to place the topic upon the broadest clinical base. Samples 
of virtually every sort of mental disease and of several sorts 
of nervous disease have been laid down, some obviously not 
instances of Shell-shock, some mixed with clinical phenomena 
of Shell-shock, others hard to tell offhand from Shell-shock — 
the whole on the basis that we shall earliest learn what 
Shell-shock, the pathological event, is by studying what it 
is not. As the sequel may show, we are perhaps not 
entitled to regard Shell-shock, the pathological event, as 
always associated with shell-shock, the physical event. We 
shall, therefore, find in Section A (see tables on pages 6 
and 7. 

(1) Cases without either physical shell-shock, or patho- 
logical Shell-shock — psychoses of various kinds incidental 
in the war ( h). 

(2) Cases with physical shell-shock but without patho- 
logical Shell-shock — psychoses of various kinds seemingly 
liberated by, aggravated by, or accelerated by the physical 
factor of shell-shock (+ — +)• 

(3) Cases without physical shell-shock but with both 
symptoms of pathological Shell-shock as well as of other 
psychosis (— + +). 

(4) Cases with physical shell-shock, with clinical phe- 
nomena of Shell-shock, as well as of other psychosis (+ + +). 



PSYCHOSES 5 

At the end of Section A, accordingly, we shall be left with 
two more formulae for discussion in Sections B, C, and D, viz: 

(5) Cases without physical shell-shock but with symptoms 
of pathological Shell-shock (— + — ). 

(6) Cases with physical shell-shock and pathological Shell- 
shock ( + + -). 

The data of Section A will solidly prove that Shell-shock, 
however picturesque the term for laymen or in the argot of 
the clinic, is medically most intriguing. As we cannot get 
rid of the term (even by suppressing it in parentheses or by 
condemning it to the limbo of the so-called), we must make 
the best of it by calling Shell-shock just the ore in the clinical 
mine. To say the least, the term is harmless: it merely stimu- 
lates the lay hearer to questions. These questions he must 
ask of the expert. But every time that the expert suavely 
states that Shell-shock is nothing but psychoneurosis, that 
expert runs the risk of hurting some patient|who may or not 
have a psychoneurosis but has been called psychoneurotic. 
All the while, of course, the suave expert is perfectly right — 
statistically. In fine, the man you have called a victim of 
Shell-shock is probably a victim of psychoneurosis, but only 
probably ! 

Section A shows how he may — not probably, but possibly 
— be a victim of say ten other things. But it is not that he 
has an even chance of being one of these ten other things. 
As the reader watches the procession of cases in Section A, 
he will perceive that, amongst the ten major groups there 
studied, some have far greater diagnostic likelihood than 
others. Thus, syphilis, epilepsy, and somatic diseases will in 
the sequel prove more dangerous to our success as diagnos- 
ticians than, e. g., feeblemindedness or even perhaps alcohol- 
ism. But now let us look at these cases systematically, just 
as if we dealt with so many cases of Railway-spine or any 
other "incipient, acute, and curable" cases. 



6 



PSYCHOSES 



PSYCHOPATHIA MARTIALIS 

1 1 


SHELL-SHOCK 


1 i 

SHELL-SHOCK PSYCHOSIS 


(the physical fac- 


(neurotic symptoms) (symptoms non- 


tor) 


neurotic) 


Absent 


Absent INCIDENTAL 


Present 


Absent LIBERATED, 




AGGRAVATED, 




ACCELERATED 




PSYCHOSES 


Absent 


COMBINED NEUROSES 




AND PSYCHOSES 




* (Formula — -f +) 


Present 


COMBINED NEUROSES 




AND PSYCHOSES 




(Formula + + +) 


Absent 


NEUROSES Absent 




(Quasi Shell-shock) 


Present 


NEUROSES Absent 




(True Shell-shock) 


* For formulae see Chart 3 on opposite page. 




Chart 2 



PSYCHOSES 









C u 




PSYCHOPATHIA MARTIALIS 






FORMULAE 




S, N, P* = 


SHELL-SHOCK 


1 

SHELL-SHOCK 


PSYCHOSIS 


P = 


(the PHYSICAL f 
factor) present 


(neurotic symptoms) 

PRESENT 


(non-neurotic 
symptoms) pres- 
ENT 
+ 


SP = 


+ 


- 


+ 


NP = 


- 


+ 


+ 


SNP = 


+ 


+ 


+ 


1 N = 


- 


+ 


- 


SN = 


+ 


+ 


- 


* In the literal formulae, S = 


Shell-shock, N = Neurosis, P = Psychosis. 


t These plus-or-minus formulae are not intended to imply that the 
physical factor, where present (+), must have worked a physical effect 
upon the nervous system: the effects of the physical factor might be 
wholly emotional or otherwise psychic. 








Chart 3 



I. SYPHILOPSYCHOSES 
(SYPHILITIC GROUP) 



An officer of high rank deserts his command in a 
crisis : alienists* report. 



Case i. (Briand, February, 1915.) 

M. X. was an officer ranking high in the French army, 
having military duties of a critical nature and of great im- 
portance (social reasons forbid Briand' s giving informatory 
details). Suffice it to say that he was brought before court- 
martial for abandoning his post at the very moment when 
his presence was most urgently required. He turned tail, 
without taking the most elementary military precautions. 

M. X. was passed up to alienists. He was not a case of 
Shell-shock unless of the anticipatory sort. He was somati- 
cally run-down and of lowered morale and now 65 years of age. 
The campaign had been fatiguing. 

The alienists decided that the officer had not been respon- 
sible for his non-military acts. He had been, they found, in 
a state of mental confusion at the time of desertion, such that 
amnesia for his duties and heedlessness of consequences had 
allowed him to leave the front without looking behind him 
or securing substitution. This state of mental confusion had 
been preceded by overwork and several nights of insomnia. 

Moreover he was palpably arteriosclerotic. Blood pressure 
was high. The history was one of slight shocks and a mild 
hemiplegia. The confusion at the front was only the most 
recent of a series of transitory attacks of confusion. At the 
time of examination this high officer was actually in a state 
of mild dementia. 

M. X. was an old colonial man, malarial, and had been a 
victim of syphilis. 



SYPHILOPSYCHOSES 



A naval officer sees hundreds of submarines: 
General paresis. 



Case 2. (Carlill, Fildes, and Baker, July, 191 7.) 

A naval officer, 36, during August, 1916, asserted that he 
could see hundreds of submarines. At one time he imagined 
that he was receiving trunk calls in the middle of the ocean. 
He was admitted to Haslar, and the Wassermann reaction 
of the serum was found strongly positive. The spinal fluid 
was not at this time examined. The officer recovered to 
some extent, was given no special treatment, and was sent 
on leave. 

He came under observation again in October, 19 16, having 
become very strange in his manner, on one occasion passing 
water into the coal box, and talked about impending elec- 
trocution. His ankle- jerks were found sluggish and there 
was a patch of blunting to pin pricks. The diagnosis of 
general paresis was made. The spinal fluid was afterward 
examined and found to be negative to the Wassermann 
reaction but contained 15 lymphocytes per cubic mm. 

Three full doses of Kharsivan freed him from delusions and 
left him apparently absolutely sane. It was recommended 
that he should be kept at Haslar to continue treatment. 
However, he had been certified insane and was therefore sent 
to Yarmouth, from which he was discharged in February, 
191 7, having been in good mental health throughout his stay 
there. 

Re syphilis and general paresis of military officers, as in 
Cases 1 and 2, Russo-Japanese experience was already at 
hand. Autokratow saw paretic Russian officers sent to the 
front in early but still obvious phases of disease. These 
paretics and various arteriosclerotics, Autokratow saw back 
in Russia in the course of a few months. 

Re naval cases, see also Case 5 (Beaton). Beaton thinks 
that monotonous ship duty, alternating with critical stress 
of service, bears on morale and liberates mental disorder. 



I O SYPHILOPS YCHOSES 



Neurosyphilis may be aggravated or accelerated 
under war conditions. 



Case 3. (Weygandt, May, 191 5.) 

A German, long alcoholic and thought to be weakminded, 
volunteered, but shortly had to be released from service. 
He began to be forgetful and obstinate, cried, and even 
appeared to be subject to hallucinations. The pupils were 
unequal and sluggish. The uvula hung to the right. The 
left knee-jerk was lively, right weak. Fine tremors of hands. 
Hypalgesia of backs of hands. Stumbling speech. Atten- 
tion poor. 

It appeared that he had been infected with syphilis in 1881 
and in 1903 had had an ulcer of the left leg. 

The military commission denied that his service had 
brought about the disease. 

Case 4. (Hurst, April, 1917.) 

An English colonel thought himself perfectly fit when he 
went out with the original Expeditionary Force. He had had 
leg pains, regarded as due to rheumatism or neuritis. He 
was invalided home after exhaustion on the great retreat. 
He was now found to be suffering from a severe tabes. He 
improved greatly under rest and antisyphilitic treatment. 
He has now returned to duty. 

Case 5. (Beaton, May, 1915.) 

An apparently healthy man, serving on an English battle- 
ship, severed a tendon in a finger. The injury was regarded 
as minor. The tendon was sutured and the wound healed. 
During the man's convalescence he was accidentally discovered 
to have an Argyll- Robertson pupil and some excess reflexes. 
Neurosyphilis had probably antedated the accident. But 
from the moment of this trivial injury, the disease advanced 
rapidly. 



SYPHILOPSYCHOSES 1 1 



Overwork in service ; several months exacting work 
well performed : General paresis. 



Case 6. (Boucherot, 1915.) 

A lieutenant of Territorials, aged 41 (heredity good, anal 
fistula at 30, with ulceration of penis of an unknown nature 
at the same period). In 1907 when off service and married, 
his wife gave birth to a child; no miscarriages. Had been a 
good soldier in service before the war. The lieutenant was 
called to the colors August 2, 19 14, and was detached for 
special duty, for the performance of which he was much 
praised by the commanding officers. The work, however, 
was too much for him and on April 1 he had to be evacuated 
to the hospital with a ticket saying " Nervous depression 
following overwork in service." On April 14 he seemed well 
enough for a convalescent camp, but, apparently through 
red tape, was sent to a hospital at Orleans. On June 23 he 
had to be evacuated to the Fleury annex. His eyes were dull 
and features flaccid; his whole manner suggested fatigue. 
His pupils were myotic, tongue tremulous, speech slow and 
stumbling. Knee-jerks were exaggerated and gait difficult, 
the right leg dragging. Headaches. He could not perform 
the slightest intellectual work and was the victim of retro- 
grade and anterograde amnesia. He was aware of the decline 
of his mental power and was fain to struggle against it, 
becoming restless and sad. The gaps in his memory grew 
deeper, he became more and more impulsive, even violent, 
and had spells of excitement. Dizziness and palpitation 
developed. Sometimes there were auditory and visual 
hallucinations of such intense character that he tried feebly 
to commit suicide with a penknife. He fell into semicoma, 
and then had a number of apoplectiform attacks. W. R. + 

Apparently the moral and physical situation of the lieu- 
tenant was absolutely normal when the campaign began and, 
as he fulfilled detail duties with absolute correctness for a 
number of months, Boucherot argues that here is an instance 
of general paresis declanche by overwork. 



12 SYPHILOPSYCHOSES 



Syphilis contracted before enlistment. Neuro- 
syphilis aggravated by service. 



Case 7. (Todd, personal communication, 1917.) 

A laboring man, 42, who always strenuously denied syphi- 
litic infection, proceeded to France eight months after enlist- 
ment. He had not been in France three weeks when he 
dropped unconscious. He regained consciousness, but re- 
mained stupid, dull in expression, and with memory impaired. 
His speech was also impaired. There was dizziness and a 
right-sided hemiplegia. 

He was confined to bed four months and was then "boarded" 
for discharge. 

Physically, his heart was slightly enlarged both right and 
left ; sounds irregular ; extra systoles ; aortic systolic murmur 
transmitted to neck; blood pressure 140:40. Precordial 
pain, dyspnoea. 

Neurologically, there was a partial spastic paralysis of the 
right thigh which could be abducted, could be flexed to 120 , 
and showed some power in the quadriceps. There was also 
a spastic paralysis of the right arm, but the shoulder girdle 
movements were not impaired. There was a slight weakness 
on the right side of the face. There was no anesthesia 
anywhere. 

The deep reflexes were increased on the right side, Babinski 
on right, flexor contractures of right hand, extensor contrac- 
tures of right leg, abdominal and epigastric reflexes absent, 
pupils active, tongue protruded in straight line. 

Fluid : slight increase in protein. W. R. + + + 

The Board of Pension Commissioners ruled that the condi- 
tion had been aggravated by service (not " on service "). 

Re general paresis, Fearnsides suggested at the Section of 
Neurology in the Royal Society of Medicine early in 1916, 
that in all cases of suspected Shell-shock the Wassermann 
reaction of the serum should be determined, and went on to 
say that cases of so-called Shell-shock with positive W. R. 
often improve rapidly with antisyphilitic remedies. 



SYPHILOPSYCHOSES 1 3 

Duration of neurosyphilitic process important re 
compensation. 



Case 8. (Farrar, personal communication, 191 7.) 

A Canadian of 36 enlisted in 191 5, served in England, and 
was returned to Canada in February, 191 7, clearly suffering 
from some form of neurosyphilis (W. R. positive in serum 
and fluid, globulin, pleocytosis 108). 

There is no record of any disability or symptom of nervous 
or mental disease at enlistment. The first symptoms were 
noted by the patient in May, 191 6, six months or more after 
enlistment. The case was reviewed at a Canadian Special 
Hospital, October 11, 1916, by a board which reported: 

"The condition could only come from syphilitic infection 
of three years' standing " (a decision bearing on compensa- 
tion) ; but the general diagnosis remained : 

"Cerebrospinal lues, aggravated by service." 

The picture which the medical board regarded as of at least 
three years' standing was as follows: 

History of incontinence, shooting pains, attacks of syncope, 
general weakness, facial tremor, exaggerated knee-jerks, 
pupils react with small excursion. Speech and writing dis- 
order, perception dull, lapses of attention, memory defect, 
defective insight into nature of disorder, emotional apathy. 

1. Was the conclusion "aggravated by service " sound? 

On humanitarian grounds the victim is naturally con- 
ceded the benefit of the doubt. But it is questionable 
how scientifically sound the conclusion really was. 

2. Could the condition come only from syphilitic infection 

of at least three years' standing? Hardly any single 
symptom in this case need be of so long a standing; yet 
the combination of symptoms seems by very weight of 
numbers to justify the conclusion of the medical board. 

Farrar's case and thirteen others of " Neurosyphilis and 
the War" were included in a general work on Neurosyphilis 
(Case History Series, 191 7, Southard and Solomon). For 
military syphilis in general, see Thibierge's Syphilis dans 
V Armfe (also in translation). 



1 4 SYPHILOPSYCHOSES 



General paresis lighted up by the stress of military 
service without injury or disease? 



Case 9. (Marie, Chatelin, Patrikios, January, 1917.) 

In apparently good health a French soldier repaired to the 
colors, in August, 1914, being then 23 years old. 

Two years later, August, 1916, symptoms appeared: 
speech disorder with stammering, change of character (had 
become easily excitable), stumbling gait. He became more 
and more preoccupied with his own affairs, grew worse, and 
was sent to hospital in October, 191 6. 

He was then foolish and overhappy, especially when inter- 
viewed. There was marked rapid tremor of face and tongue. 
Speech hesitant, monotonous, and stammering to the point 
of unintelligibility. His memory, at first preserved, became 
impaired so that half of a test phrase was forgotten. Simple 
addition was impossible and fantastic sums would be given 
instead of right answers. Handwriting tremulous, letters 
often missed, others irregular, unequal, and misshapen. 

Excitable from onset, the patient now became at times 
suddenly violent, striking his wife without provocation. 
After visit at home, he would forget to return to hospital. 
Often he would leave hospital without permission (of course 
the more surprising in a disciplined soldier). No delusions. 

Serum and fluid W. R. positive; albumin; lymphocytosis. 

Neurological examination: Unequal pupils, slight right- 
side mydriasis, pupils stiff to light, weakly responsive in 
accommodation, reflexes lively, fingers tremulous on exten- 
sion of arms. 

The patient had, December 5, 191 6, an epileptiform attack 
with head rotation, limb-contractions and clonic movements. 
Should this soldier recover for disability obtained in service? 
Marie was inclined to think military service in part responsible 
for the development of the paresis. Laignel-Lavastine 
thought so also, but that the amount assigned should be 5%- 
10% of the maximum assignable. 



SYPHILOPSYCHOSES 1 5 



SYPHILITIC ROOT-SCIATICA (lumbosacral 
radiculitis) in a fireworks man with a French artil- 
lery regiment. 



Case 10. (Long (Dejerine's clinic), February, 1916.) 

No direct relation of this example of root-sciatica to the 
war is claimed nor was there a question of financial reparation. 

There was no prior injury. At the end of March, 1915, 
the workman was taken with acute pains in lumbar region 
and thighs, and with urgent but retarded micturition. 

Unfit for work, he remained, however, five months with the 
regiment, and was then retired for two months to a hospital 
behind the lines. He reached the Salp£triere October 12, 
19 1 5, with "double sciatica, intractable." 

There was no demonstrable paralysis but the legs seemed 
to have "melted away," fondu, as the patient said. Pains 
were spontaneously felt in the lumbar plexus and sciatic 
nerve regions, not passing, however, beyond the thighs. 
These pains were more intense with movements of legs; but 
coughing did not intensify the pains. Neuralgic points could 
be demonstrated by the finger in lumbar and gluteal regions 
and above and below the iliac crests (corresponding with 
rami of first lumbar nerves). The inguinal region was 
involved and the painful zone reached the sciatic notch and 
the upper part of the posterior surface of the thigh. 

The sensory disorder had another distribution, objectively 
tested. The sacral and perineal regions were free. Anes- 
thesia of inner surfaces of thighs, hypesthesia of the anterior 
surfaces of thighs and lower legs. The anesthesia grew more 
and more marked lower down and was maximal in the feet, 
which were practically insensible to all tests, including those 
for bone sensation. There was a longitudinal strip of skin 
of lower leg which retained sensation. 

Position sense of toes, except great toes, was poor. There 
was a slight ataxia attributable to the sensory disorder — 
reflexes of upper extremities, abdominal, and cremasteric 
preserved, knee-jerks, Achilles and plantar reactions absent. 



1 6 SYPHILOPSYCHOSES 

The vesical sphincter shortly regained its function, though 
its disorder had been an initial symptom. Pupils normal. 

The " sciatica" here affects the lumbosacral plexus. 

As to the syphilitic nature of this affection, there had been 
at eighteen (22 years before) a colorless small induration of 
the penis, lasting about three weeks. There was now evident 
a small oval pigmented scar. The patient had married at 
20 and had had three healthy children. 

The lumbar puncture fluid yielded pleocytosis (120 per 
cram.). Mercurial treatment was instituted. 

The treatment has not reduced the pains. Long thinks it 
was undertaken too long (six months) after onset. The 
warning for early diagnosis is manifest. There was somehow 
a delay under the medical conditions of the army. 

Re syphilis in munition-workers Thibierge has much to 
say of French conditions. Throughout his work on syphilis 
in the army, he stresses the large number of venereal cases 
in men mobilized for munition- work. Medical inspections 
ought, according to Thibierge, imperatively to be made in 
the munition-works and upon all mobilized workmen, whether 
French or belonging to the Colonial contingents. These men 
are under military control in France, but they have more 
opportunities than the soldiers for contracting and dissemi- 
nating syphilis. They are, in point of fact, very often in- 
fected and in a higher proportion than are the soldiers at 
the front. The munition-workers should also be obliged to 
report their infections to the physician, whether or no they 
are under treatment by military or by private physicians. 

Thibierge devotes a chapter to syphilis as a national danger. 
Not only do available statistics prove that there is more 
syphilis in the population since the outbreak of war, but 
the number of married women going to special hospitals for 
syphilis is abnormally high and entirely out of proportion 
to the number of married women resorting to these clinics in 
peace times. A certain number are contaminated by their 
husbands on leave. Thibierge calls attention to the fact of 
the extraordinary frequency of syphilis in young men (two 
or three, sixteen to eighteen years of age, at Saint-Louis 
Hospital at each consultation). 



SYPHILOPSYCHOSES 1 7 

A disciplinary case : Syphilitic? 



Case 11. (Kastan, January, 1916.) 

Reports varied about a certain German soldier who came 
up for discipline. Inferiors thought he was harsh and tricky. 
A lieutenant declared that the man always wanted to have 
proper respect paid to him, and that he was unduly excited 
by trifles. The man had become latterly very nervous on 
account of battle strain and protracted shelling. 

July 28, 1 91 5, the man, who had been drinking with com- 
rades the night before, was excitedly talking to an officer con- 
cerning relief of a guard. The soldier stated, "Asa sergeant 
on duty with a service record of 1 5 years, I think it is my affair." 
The lieutenant replied, "So far as I am concerned, the matter 
is settled." The sergeant yelled, "As far as I am concerned, 
it is settled also. By the way, my name is Mr. Vice Ser- 
geant . . . ," and with that the sergeant wrote down the 
lieutenant's words and refused to obey the lieutenant's order 
to "Stop writing." The lieutenant drew his sword and said, 
"Take your hands down." The sergeant replied, "Surely 
I am permitted to write." Lieutenant: "Subordination; 
don't forget yourself, Vice Sergeant ... ." The sergeant 
jeered, "You forgot yourself anyhow;" whereupon the lieu- 
tenant: "Well, such a thing never happened to me before." 
The sergeant, jeeringly, "Nor to me either. If I were not in 
undress I should know what to do." The lieutenant: "Vice 
Sergeant . . . , remain here. This matter will be settled at 
once." The sergeant: "It is Mr. Vice Sergeant . . . ," 
whereupon he gave his notebook to a hornblower and said, 
"Write." The lieutenant: "Stay." The sergeant: "What, 
stay here. No, I'll not stay," and made off. The lieutenant 
called after him, "Put on your service dress and see the 
captain." He made ready but said, "This half-idiot gives 
an order like that to a sergeant with 15 years' record." 

The examination showed that the man had a hypalgesia. 
He complained of violent headaches. He said that he had 
had syphilis 10 years before; there were no bodily stigmata. 



1 8 SYPHILOPSYCHOSES 



Regulations broken : General paresis. 



Case 12. (Kastan, January, 191 6.) 

A German ist-lieutenant, on active service before the war, 
had left the service because there was not enough for him to 
do in peace times. During his war service, he became drunk 
and had two soldiers bound to a doorpost, with coats un- 
buttoned and without their caps — a process quite verboten. 
While in Konigsberg, he reported himself ill, and failed to 
go to a designated hospital. He was accordingly treated 
as a deserter. He ran up bills with landlady and servant 
girls, saying that he was going to receive money from his 
wife. Under hospital examination, he said he was only a 
Baden man with a lively temperament. He got angry at 
the phrase test feeding, refused food, got excited when asked 
to help in the care of other patients, and wrote a letter saying, 
"If it is the idea to make me nervous by removing the air 
from me, by prescribing rest in bed — a punishment only 
suitable for a boy who cannot keep himself neat — and such 
chicaneries, these philanthropic attempts are bound to fail 
on my robust peasant nerves. Of course I know that money 
considerations make the stay of every paying patient desir- 
able, but I am really too good for that. [The expenses were 
being borne by the state.] I have openly stated what is being 
here done with me is foolery, and I stick to that phrase. The 
food, already poor enough, is no better, when the meat of a 
half- rotten cow comes twice to the table.' ' This patient was, 
according to Kastan, a victim of general paresis. 

Re general paresis and delinquency, Gilles de la Tourette 
long ago maintained that there was a medicolegal period in 
paresis. Lepine in his work on Troubles Mentales de la 
Guerre speaks of the unexpected frequency of general paresis 
in the army, and calls attention at the outset to the medico- 
legal period. The danger of overt delinquency is, in fact, 
greater under military than under civilian conditions on ac- 
count of the closer surveillance of the soldier. Desertion 
and thievery are the main forms. 



SYPHILOPSYCHOSES 1 9 

Unfit for service : General paresis. 



Case 13. (Kastan, January, 1916.) 

Kastan describes a non-commissioned officer, who came 
voluntarily into the clinic. It seems that he had absented 
himself (?) from the army in the suburbs of Konigsberg, 
September 3, 1914. He was arrested October 7th. Once 
before he had been brought to Kastan's clinic on the suspicion 
of general paresis, but had been dismissed as non-paretic. 
Brought in again in a condition of marked fear, he declared 
that he had to fall behind his company while he was on the 
march on account of a feeling of weakness. He had been 
taken to a hospital and then carried to the suburbs of Konigs- 
berg, examined, and found unfit for service. 

He had in his 20th year become infected with syphilis, and 
had recently become forgetful, subject to fears, and easily 
excitable. He had been very unhappily married with a 
woman who was hysterical and threatened to shoot and 
poison him. He lived in a condition of continual quarrels 
with her. The symptoms that he felt on the march were 
numbness of the legs and a rush of blood to the head. In 
the clinic, he was subject to much dreaming and raving about 
the war. There was excessive perspiration. 

1. As to the proper interpretation of this case, details are 
lacking as to the physical and laboratory side. In fact, 
it would appear that the suspicion of paresis at his first 
reception in a clinic was dismissed without resort to 
laboratory findings. 

There are no neurological symptoms in the case 
clearly suggestive of neurosyphilis, except perhaps the 
numbness of the legs. The remainder of the picture 
appears to be entirely psychic. Sensory and intellec- 
tual symptoms are missing unless we count the war 
dreams and mania as intellectual. It appears wiser 
to count these as emotional in the sense that they were 
roused by emotion-laden memories. The fear, per- 
spiration, and feelings of head flush are perhaps to be 
best interpreted as satellites about an emotional nucleus. 









20 SYPHILOPSYCHOSES 



Hysterical chorea versus neurosyphilis. 



Case 14. (De Massary and Du Sonich, April, 1917.) 

There were various complications in the case of a lieutenant 
(nervous tic in childhood; travel 23 to 30), who was at Ant- 
werp during the period of mobilization. He was taken there 
by the Germans; was a prisoner in their hands for 55 days; 
and succeeded under great strain in escaping. 

He then entered his regiment, and, passing the examina- 
tions, was made an adjutant, and went to the front, March, 
1 91 5. He stayed ten months in the Verdun region, under 
heavy bombardment, and in June was bowled over and buried 
by a 210. He seemed to be fearless, getting no sensation 
from shell-bursts except a griping sensation in the bowels. 

However, his character had altered in the direction of 
irritability; and by the end of January, 191 6, he had to be 
evacuated for the first time from the front, for general weak- 
ness, with the diagnoses: neurasthenia, neuralgia, dyspeptic 
troubles, great general fatigue, marked depression. In fact, 
at Narbonne he was asked no questions for several days on 
account of his obvious depression. He was given ice-bags 
for violent headaches, complete rest in bed, cacodylate and 
sodium nucleinate. In two weeks he was up and about. 

At this time appeared choreiform movements, which 
reached their maximum in two or three days, whereupon he 
was sent, March 4, 1916, to the neurological centre at Mont- 
pellier. Here W. R. positive! Neosalvarsan on the second 
injection (0.45 and 0.60) yielded a strong reaction, with fever, 
delirium, vomiting, and then jaundice. 

About a month later, he was given twenty more intra- 
venous injections, whereupon the choreic movements now 
decreased, and July 15 he was given convalescence for three 
months. October 15 he went back to his depot cured; and 
October 20, on request, went to the front. He was potted 
and under machine-gun fire at times during the next three 
months, but the choreic movements did not reappear. Janu- 
ary 1 he left the trenches as the division went into billets. 



SYPHILOPSYCHOSES 2 1 

January 8, suddenly, without any emotional cause, he began 
to "dance" again. Accordingly, he was evacuated for the 
second time, January 10, 1917, with the diagnosis: choreic 
movements, especially on left; evacuate to special centre. 

At Royallieu, a lumbar puncture showed a slight lympho- 
cytosis. The headache improved. He was evacuated Janu- 
ary 24, 1917, to Val-de-Grace, with a diagnosis: Recurrent 
chorea; first attack followed commotio cerebri, nervous de- 
pression, inequality of pupils, various pains, contracted in 
the army. Another W. R. was positive. Twelve intra- 
muscular injections of oxygen cyanide were given, besides 
baths. He was then sent to Issy-les-Moulineaux with a 
diagnosis of tic. He showed choreiform movements affecting 
the legs alone. When sitting, legs extended and flexed, the 
knees would abduct, then adduct; the thighs flexed. When 
standing, flexor movements were produced alternately on the 
left and the right, the knee being raised high, sometimes 
striking the patient's hand. In walking, the thigh and lower 
leg flexion was always out of proportion to the required step. 
There was thus a sort of saltatory chorea limited to the legs. 
The reflexes so far as they could be tested were normal save 
that the left pupil was fixed to light and accommodation; the 
right pupil was sluggish to light but accommodated normally. 
Leucoplakia of the cheeks; nocturnal headaches; and pains 
resembling lightning pains in arms and legs. Lumbar punc- 
ture, March 26, showed blood-stained fluid, and the puncture 
was followed by headache, vomiting, and slow pulse. The 
fluid showed a slight lymphocytosis; W. R. negative. 

It is clear that a diagnosis limiting itself to the leg trouble 
would probably content itself with "hysterical chorea.' 9 The 
lieutenant said that when he saw people "dance " he did have 
a tendency to imitate them ; and when he was cured of that, 
he did not want to go to Lamalou because he would see the 
ataxic patients there and might fall back into his "dancing." 
However, in view of the pupillary inequality, the lympho- 
cytosis, the leucoplakia, the W. R., and the initial neuras- 
thenia and depression found in the very first hospital in which 
he was examined, we probably should be entitled to consider 
that general paresis played a part in the chorea. 



22 SYPHILOPSYCHOSES 

Shrapnel fragment driven through skull: General 
paresis. 



Case 15. (Hurst, April, 1917.) 

A private, 31, was wounded December 7, 191 6, by a shrap- 
nel fragment which entered the skull above the left ear and 
lodged in the brain, an inch above and 2\ inches below the 
middle of the right orbital margin. At Netley, December 30, 
he proved to show a complete internal and external left sided 
ophthalmoplegia, with the exception of the external rectus. 
On the right side, there was a complete paralysis of the superior 
rectus and a partial paralysis of the inferior rectus and levator 
palpebrae superioris. There was a paresis of the left side of the 
face. The right plantar reflex was said to have been extensor 
at the clearing station, but at Netley it and the other reflexes 
proved to be normal, as were the optic. The patient was 
stuporous and had incontinence of urine and feces for two 
days. Shortly after admission, slurring of speech with a long 
latent period occurred. It was clear that the shrapnel frag- 
ment must have passed far above the crus, and it was not 
plain how isolated lesions of the third and seventh nerve 
nuclei could have been brought about without injury of the 
long tracts of the crus. 

The Wassermann reaction of the serum was negative, but 
that of the spinal fluid was positive. Iodide and mercury 
secured considerable improvement in the mental condition 
and some diminution in the paralysis. The patient is now 
extremely pleased with himself and has a speech suggestive 
of paresis. 



SYPHILOPSYCHOSES 



23 



Head trauma: Shell-shock effects, over in a few 
months, Manic-depressive (?) attack more than 
two years later. X-ray evidence suggesting brain 
lesion. Serum Wassermann reaction positive. 



Case 16. (Babonneix and David, June, 191 7.) 

A bullet glancing from his gun barrel November 28, 1914, 
wounded a man in the head, whereupon he lost consciousness 
and was carried to a hospital and trephined. On coming to, 
he found that he could not hear and felt pains; but the latter 
disappeared in a few months. He was given sedentary 
employment and did his work properly until February, 191 7, 
when he suddenly became sad, wept, slept poorly, stopped 
eating, had an absent air, and began to complain of his head. 
He passed whole days without moving, in a sort of stupor, 
which was then followed by a hypomaniacal agitation in 
which he walked furiously up and down in the room and threw 
objects about. 

He was found subject to a generalized tremor and he was 
distinctly weaker on the right side. The tendon reflexes 
were excessive. The bony sensibility, as well as the pain and 
temperature sense, and the position and stereognostic senses 
were completely abolished on the right side. The scar lay 
on the left side. It was deep and very sensitive to pressure, 
so that if it was touched ever so slightly the patient began to 
weep. X-ray indicated loss of substance in the posterior part 
of the left parietal region. Remains of the projectile were 
found subcutaneously in the right supraorbital region. The 
W. R. of the serum was positive. There was no lympho- 
cytosis in the spinal fluid. 

Interpretation of this case is manifestly difficult. Four 
possibilities exist : Syphilis, manic depressive psychosis, trau- 
matic brain disease, and functional shock effects. More 
than two years had passed between the trauma and the 
change of character. 



24 SYPHILOPSYCHOSES 

Skull trauma in a syphilitic. 



Case 17. (Babonneix and David, June, 191 7.) 

A soldier, 31, sustained fracture of the occiput from shell- 
burst, and thereafter showed confusion and total loss of 
memory. Operation November 1 1 withdrew bony fragments 
and clots, whereupon the man returned practically to normal. 
He developed, however, a few seizures, in which he struggled, 
fell, and lost consciousness, afterward suffering from head- 
ache. The tendon reflexes were increased. The occipital 
cicatrix was a little depressed and slightly painful on pressure. 

Lumbar puncture showed a very slight lymphocytosis (5 
to 6 cells), practically negative globulin reaction, and a low 
albumin titer. There were no signs of syphilis in the eyes. 
The W. R. in the serum was strongly positive. Very possibly 
the traumatic phenomena in this case can be safely disengaged 
from the syphilitic phenomena. 

Re the mechanism by which trauma evokes or accelerates 
the course of neurosyphilis, it is probable that most neuro- 
pathologists believe that the commotio cerebri causes sundry 
chemical or physical effects in the nerve tissues such that 
spirochetes are moved into new and more dangerous places, 
or such that more appropriate food is supplied to the organ- 
isms, which then begin to multiply. Whether the organisms 
live in a kind of symbiosis in the tissues under ordinary cir- 
cumstances in the pre-paretic period of the development of 
neurosyphilis, is unknown. Possibly fat embolism should 
be added to the list of possible causes of the hastening of 
the neurosyphilitic process. Fat embolism in the brain has 
been shown by various authors to be accompanied by minute 
hemorrhages, in the midst of which by proper stains the 
fat embolism can be made out. 



SYPHILOPSYCHOSES 2$ 

Shell- wound in battle : General paresis. 



Case 18. (Boucherot, 191 5.) 

A soldier in the Territorial Infantry, 42, a gardener who went 
to taverns, as he said, "like everybody else," a widower with 
two children, a good worker though irascible, had had syphilis 
as a youth. He was called to the colors at the outbreak of the 
war and got on well despite tremendous strain. March 9, 
19 1 5, he was in a bayonet charge with his regiment and was 
bowled over by a shell of which a fragment wounded him 
above the knee and several fragments in the thorax. All 
these fragments were extracted at a temporary hospital, 
March 11. The man now became strange, refused to obey 
orders and did a number of peculiar things so that he was 
sent to Orleans temporary hospital whence he was evacuated 
to Fleury Asylum, March 19. He refused to give up his 
things because he was the master. He did not want to go to 
bed and wanted to keep on walking constantly. He was 
without sense of shame, satisfied with himself, grandiose as 
to his millions in bank and the thirty-six decorations he 
believed had been awarded him. He mistook the identity of 
the landscape and of the people about him. 

Tongue tremulous; pupils unequal; knee-jerks exaggerated; 
dysarthria; gaps in memory. In May occurred a number 
of violent reactions. 

In June, however, there was a remission; the ideas of 
grandeur disappeared first, then the tremors and reflex dis- 
order and finally the speech disorder. There was a slight 
seizure at this point and the man said he had had another 
such just before he came to the army. July 20 he was in- 
valided out much improved. 

In this case of general paresis there is, besides the syphilis, 
also alcoholism to consider, so that it is not entirely plain 
that the exertions of campaign liberated the paresis. 

Re wounds and paresis, see also Case 5 (Beaton), in which 
neurosyphilis advanced rapidly from the time of a trivial 
injury. 



26 SYPHILOPSYCHOSES 

Shell-explosion : Syphilitic ocular palsy. 



Case 19. (Schuster, November, 1915.) 
Schuster notes briefly a curious result of the explosion of a 
shell, which caused the patient in question to lose conscious- 
ness. Shortly after the explosion, the patient came to his 
senses again, but a surprising paresis of the eye muscles had 
developed. This paresis looked precisely like a syphilitic 
paresis clinically. 

Examination of the blood serum yielded a strongly positive 
Wassermann reaction. 

According to Schuster, the explosion of the shell had 
brought about hemorrhage in vessels supplying the region 
of the eye muscle nerves or nuclei. The reason for the selec- 
tion of these vessels for rupture due to shell explosion is, 
according to Schuster, that the vessels were probably already 
syphilitically diseased. 

Re hemorrhages in the neighborhood of the oculomotor 
nuclei, the phenomena of polioencephalitis may be recalled. 
In that disease, the predisposition to hemorrhage is presumed 
to be alcoholic, as the cases of ophthalmoplegia of this group 
almost always appear in alcoholics. However, the first case 
of hemorrhagic superior polioencephalitis was a non-alcoholic 
one of Gayet (1875), in which the symptoms followed three 
days after a boiler explosion. 



SYPHILOPS YCHOSES 2 7 

A tabetic lieutenant " shell-shocked " into paresis? 



Case 20. (Donath, July, 1915.) 

An apparently competent German professor in an inter- 
mediate school, a lieutenant of infantry reserves, 33 years 
old, on the 17th August, 1914, was stunned for a while by 
the shock of a cannon-firing 25 feet away. Urination became 
difficult. Headaches and limb pains ensued, with paralysis 
of fingers, gastric troubles, forgetfulness, especially for names, 
insomnia, and general scattering of mental faculties. 

Neurologically, the pupils were irregular, left larger than 
right; Argyll- Robertson reaction. Right knee-jerk livelier 
than left. Achilles reactions absent. Slow and dissociated 
pain reactions in feet, lower thighs and lower quarter of upper 
thighs, with hypalgesia or analgesia. Station good; gait 
steady. Mentally depressed, slow of thought. Speech poor 
and of indistinct construction (mild dementia). Calculation 
ability poor. No pleasure in work. 

Wassermann reaction of serum weakly positive. 

It seems that for a year the patient had been subject to 
spells of anger. He was irritated by his wife who had been 
nervous since an earthquake. 

On the occasion of the earthquake, 191 1, the patient himself 
had had a spell of difficulty with urination. The spell had 
lasted two or three months. The patient had had a chancre 
in 1902, " cured " in four or five weeks with xeroform. In 
1908, when about to marry, he had had six mercurial inunc- 
tions. 

Re tabes, Lepine shows that tabetics are numerous. They 
are numerous among officers and also in the auxiliary service, 
in which latter tabetics are maintained on desk duty. Per- 
haps they had been admitted to such work as unable to 
march or fight, on the basis of having had so-called "rheu- 
matism." 



28 SYPHILOPSYCHOSES 



Shell-explosion may precipitate neurosyphilis in the 
form of tabes dorsalis. 



Case 21. (Logre, March, 1917.) 

An artilleryman, 38, had a large calibre shell explode very 
near him and afterward could not hear the whistle of a shell 
without falling down in a generalized tremor, sweating pro- 
fusely, urinating involuntarily, in a mental state approaching 
stupidity. Here was a case that might be regarded as one 
of morbid cowardice in a psychopath, following violent 
emotion. 

The artilleryman proved to be a victim of tabes and of 
general paresis. The incontinence of urine under the in- 
fluence of emotion was nothing but an effect of tabetic 
sphincter disorder. The crisis of cowardice proved nothing 
but an initial symptom of general paresis. 



Shell-explosion; burial: Tabes dorsalis incipiens. 



Case 22. (Duco and Blum, 191 7.) 

A French soldier was buried by effects of shell explosion 
September 8, 19 14. He sustained no wound or fracture. 

Incontinence of urine developed. Anesthesia of penis and 
scrotum. Reflexes absent; pupils sluggish. Wassermann 
reactions suspicious. 

The diagnosis tabes dorsalis incipiens was made (hema- 
tomyelia of conus terminalis eliminated). 

The patient was estimated to be "40% incapacitated," 
according to the French " echelle de gravite " of conditions. A 
full pension would not be justified in the opinion of the 
French authors. 



SYPHILOPSYCHOSES 29 



SHELL-SHOCK PSEUDOTABES (non-syphilitic, 
serum W. R. positive) . Improvement. 



Case 23. (Pitres and Marchand, November, 191 6.) 

Innkeeper B., 36, a shell-shock and burial victim June 20, 
1 91 5, was looked on by a number of physicians as a case of 
genuine tabes. 

Even eight months after the episode, he still showed (when 
observed by Pitres and Marchand, February 3, 191 6) 
absence of knee-jerks and Achilles jerks, a slight swaying in 
the Romberg position, pupils sluggish to light, incoordination, 
delayed sensations. There was also a history of pains in the 
legs, compared by the patient to those of sciatica. These 
pains came in crises, the longest of which had lasted 30 hours. 

It seems that this soldier's troubles began the day after his 
shock with a feeling of swollen feet and of cotton wool under 
them. He stayed on service, however, walking with increas- 
ing difficulty. 

At the time of his evacuation, July 10, he could walk with 
great difficulty. " Strips of lead were between his legs." He 
could hardly control movements in the dark, or descend 
stairs. Often his legs would bend under him. Vesical func- 
tion sluggish. 

After a few months the patient could walk better. In 
February, 191 6, he walked thrusting his legs forward trem- 
bling, and dragging toes a little. He could not support himself 
on either leg. Jerkiness and incoordination in extension or 
flexion of leg on thigh. 

The muscular weakness was decidedly against tabes or at 
all events a pure tabes. The incoordination proved to be due, 
not to loss of position sense (which was intact) but to un- 
steady muscular contractions. Deep sensibility was intact. 

There were no mental symptoms. There was a slight 
hesitation in speech and doubling of syllables, but nothing 
demonstrable with test phrases. 

The serum W. R. was positive. 



30 SYPHILOPSYCHOSES 

Shell explosion; unconsciousness: Neurosyphilis. 



Case 24. (Hurst, April, 191 7.) 

A private, 31, was in the retreat from Mons, was blown up 
by a shell and buried in May, 191 5, went back to the front 
after two months leave, was knocked unconscious by a shell 
December, 191 6. He came to himself two days later in the 
hospital, but remained confused and lethargic. In England, 
December 21, his legs were still weak and walking was 
unsteady. The right pupil reacted neither to light nor to 
accommodation and was irregular, eccentric, and dilated. 
The left pupil showed the Argyll- Robertson reaction. There 
was early primary optic atrophy. The right knee-jerk was 
slightly exaggerated. The vibration sense was reduced over 
sacrum and malleoli. At this time the man's mental condi- 
tion was practically normal. 

The Wassermann reaction of the serum and spinal fluid 
proved positive. Improvement followed rest, iodide, mer- 
cury, and seven injections of salvarsan. By the middle of 
February he was able to walk well. The right pupil regained 
its power to react to accommodation, but remained inactive 
to light. Meanwhile, the left pupil had regained a slight 
power to react to light. 

Re treatment of syphilis, both Thibierge and Lepine give 
warning of some bad results with arsenobenzol treatment, 
though Thibierge states that the number of serious accidents 
and especially of deaths has diminished more and more 
now that no arsenobenzol (drug No. 914) is given. En- 
cephalitis is the gravest of the untoward results of injection, 
sometimes appearing in young and vigorous subjects. Hem- 
orrhagic encephalitis appears to occur more frequently after 
the second injection than after the first, and according to 
Thibierge may be especially suspected in subjects who after 
the first injection present much fever, congestion of face, 
and cutaneous eruptions. Treatment in these cases should 
be suspended or given in moderate doses. 



SYPHILOPSYCHOSES 3 1 

Shell-explosion: Neurosyphilis. Fit for light duty. 



Case 25. (Hurst, April, 191 7.) 

A corporal, 26, blown up by a shell December 7, 191 6, was 
admitted to the hospital on the 13th, dazed and with symp- 
toms of a left-sided hemiplegia of organic origin. The right 
pupil was larger than the left. There was a bruise of the 
scalp in the right parietal region. The man had had syphilis 
at 16. The Wassermann reaction of the serum was strongly 
positive. Rest, salvarsan, mercury, and iodides were given, 
and the general symptoms and hemiplegia gradually dis- 
appeared, until on December 12 there was only a moderate 
weakness of the left side, with knee-jerks in excess, abdominal 
reflexes absent, and the Babinski reaction. 

The Wassermann reaction was still strongly positive. 
Salvarsan, mercury, and iodide were continued. January 6, 
191 7, the plantar reflex had become flexor. The abdominal 
reflex returned. Babinski' s second sign (combined flexion of 
thigh and pelvis) was now the only evidence of organic 
disease. Further antisyphilitic treatment removed this sign 
also. February 28, the man was discharged fit for light duty, 
with unequal pupils and positive Wassermann reaction, and 
a complete amnesia for the four weeks following his blowing 
up in the trenches. 

Re fitness for light duty, see remarks on Case 20 concerning 
desk duty for certain tabetics. 

Re the premature or unexpectedly early appearance of 
neurosyphilis under war conditions, the early claims of some 
authors have not been maintained. In the above instance, 
the infection was at 16 and the shell explosion occurred at 
26, namely, at about the right interval for the development 
of neurosyphilitic signs. Gerver states that military service 
brings out the lesions of paresis earlier than they would 
otherwise come. BonhoefTer has been unable to show that 
cerebrospinal syphilis is favored in its development by the 
exhaustion factor. 



32 SYPHILOPSYCHOSES 



SHELL-SHOCK PSEUDOPARESIS (non-syphi- 
litic). Recovery. 



Case 26. (Pitres and Marchand, November, 191 6.) 

June 19, 1 91 5, a shell exploded some distance from Lieuten- 
ant R. He remembers the gaseous smell, the bursting of 
several shells nearby and a sensation of being lifted into the 
air. When he recovered consciousness, he was in hospital 
at Paris- Plage, covered with bruises and scratches. They 
told him he had been delirious and had vomited and spat 
blood. 

June 24, his wife came to see him, but this visit he could 
not remember. Nor could his wife at first recognize him, he 
was so thin. He roused a few moments and recognized his 
wife, but relapsed into torpor again. Speech was difficult 
and ideas confused. 

A few days later he was able to rise ; but his mental status 
grew worse, especially as to speech and writing, the latter 
quite illegible. There was insomnia, or, if he slept, war dreams. 

August 7, he began a period of five months' convalescence 
passed with his family, depressed, given to spells of weeping, 
confined to bed or couch, unable to "find words," conscious 
of his state and troubled about it, speaking of nothing but 
the war, and afraid to go out for fear of ambuscade. There 
was at first a slight lameness of the right leg. Although he 
could walk, he felt pain in the knee on flexing the right leg 
on the thigh. He walked holding this leg in extension. 

On going back to the colors, he was immediately evacuated 
to the Centre Neurologique at Bordeaux, January 20, 191 6. 

Examination found a bored, impatient, irritated man, vexed 
that a man who was not sick should be sent up " comme fou." 

Omitting negative details, neurological examination showed 
slight lameness as above, body stiff and movements jerky, 
difficult, unsteady gait. The lieutenant could stand for some 
time on either leg. Tongue and face tremulous during speech. 
Limbs moderately tremulous, especially in the performance 
of test movements. 



SYPHILOPSYCHOSES 33 

Knee-jerks and Achilles jerks absent. Other reflexes, in- 
cluding pupillary, normal. Segmentary hypalgesia of right 
leg, especially about knee. Tremulous speech and writing. 
Patient would stop short in speaking for lack of words. 

Malnutrition. Appetite good, but a bursting feeling after 
meals. 

Skin dry, scaly on legs, fissured on fingers. 

Serum W. R. negative. Fluid not examined. 

Mental examination. Conscious and complaining of his 
troubles, Lieutenant R. claimed persistently that he was not 
sick. Memory for recent events was in general poor. Er- 
rands easily forgotten. Lost in the street. Complaint of 
corpse odors round him. Everybody is looking at him and 
making fun of him. He was apt to insult bystanders. He 
was afraid of German spies. Things in shops angered him 
as they seemed to him to be of German manufacture. 

There were frequent periods of depression, with pallor and 
no spontaneous speech for some hours to a half-day. Head- 
aches coming on and stopping suddenly. 

As to diagnosis, the first impression, say Pitres and Mar- 
chand, was that of general paresis. The progress of symp- 
toms after the shock was consistent with this diagnosis. The 
mental state and the physical findings seemed consistent, 
although the pupils were normal. His partial insight into 
his symptoms was not inconsistent with the diagnosis. He 
had a characteristic self-confidence. There had been four 
stillbirths (two twins); two children are alive, n and 13. 
Typhoid fever at 30. Syphilis denied. No mental disease 
in the family. 

The patient had never done military duty, having been 
invalided for ' ' right apex. " But he had volunteered and been 
accepted in September, 1914. 

How was Lieutenant R. cured? Apparently by rest in 
the Centre Neurologique. Pitres and Marchand do not 
speak of the subtle relation between mental state and 
the idea of non-return to military service. This motive 
might still work even if Lieutenant R. kept protest- 
ing sincerely that he wanted to go back into military 
service. 



34 SYPHILOPSYCHOSES 



War strain; shell explosion; unconsciousness. 
Sensory and motor disorders. Subject an old 
syphilitic. 



Case 27. (Karplus, February, 1915.) 

A captain, 34, was under much stress and strain in the field 
and gave himself over to excesses of alcohol and tobacco. 
August 25, 1914, at the Krasnik battle he suddenly saw at his 
right a gleam of fire and was afterward able to remember very 
distinctly the words of a lieutenant standing near by, "The 
man is dead." Three or four hours later he came to himself 
at a relief post, vomited and bled a good deal from nose and 
mouth. He heard later that he had been thrown on his 
back. 

Manual tremors and general pains developed in the next 
few days. Two weeks after the accident a slight nystagmus 
on looking to the left appeared, but there was otherwise no 
disorder of head or extremities. He was able to sit up, sup- 
ported by his arms, and he was able to contract his abdom- 
inal muscles normally. As for his legs, active movements 
were limited and weak. He could not lift his legs. The 
paralysis was more marked distally. He could walk with the 
support of two persons, but was unable to lift his feet from the 
ground. The right upper abdominal reflex was elicited, and 
both patellar reflexes were tolerably active. Cremasteric and 
plantar reflexes were absent. Neither of the Achilles jerks 
could be produced. There was hypesthesia and hypalgesia 
of the lower extremities, and of the back up to a horizontal 
line corresponding with the ninth dorsal segment; thermo- 
hyperesthesia and disorder of vibration sense in the lower 
legs. Both the motor and the sensory disorders were more 
marked on the right than the left. Insomnia and battle 
dreams. 

The gait disorder and paresis gradually improved. There 
was no alimentary glycosuria and adrenalin produced no 
mydriasis. In the course of several weeks the patient gained 
seven kilograms, began to sleep well and showed gradual 



SYPHILOPSYCHOSES 35 

improvement in his gait and in the execution of various 
movements with his feet. The abdominal reflexes were now 
both present, but there were no plantar reflexes and the,. 
Achilles were still both absent. The sensory disorder re- 
mained unchanged, so far as the skin was concerned, but the 
deep sensibility improved. Both legs from the knee down 
were somewhat cold. 

This man had had syphilis at twenty-two, had gone through 
an inunction cure, and repeated W. R.'s came through nega- 
tive. He had suffered from vomiting spells and anxiety feel- 
ings for a number of years which had been diagnosed by 
physicians as cardiac neurosis. Yet for a year before going 
into the war he had felt absolutely well. 



36 SYPHILOPSYCHOSES 



Shell-explosion: Amnesia; syphilitic hemiplegia. 
Recovery except for amnesia as to brief period and 
loss of occupational skill. 



Case 28. (Mairet and Pieron, July, 191 5.) 

A man of 40 underwent shell shock June 15, 191 5, and 
had no remembrance of what happened up to July, 191 5, 
when in hospital at Tunis he felt "born again." 

Examined in January, 1916, it was found that he had a 
left hemiplegia (in fact, he had a syphilitic hemiplegia on that 
side, several years before, which had disappeared under anti- 
syphilitic treatment). This hemiplegia passed, but he then 
had crises of depression due to his despair at not being able 
to know who he was and what he was doing. He could 
speak French and Spanish, and knew from the hospital ticket 
that he was born in Spain; but he had no idea what had 
happened to his relatives or what he was doing in France. 
He had, however, a very correct idea of what happened during 
six months after July, 191 5. 

One morning in April, 191 6, his old memories came back 
all of a sudden on waking. The gap was rilled up to the mo- 
ment of the shock. There was no gap left except for a period 
of about 25 days following the shock. He now found that he 
knew a little English but that he had lost his stenography 
as well as his professional skill at typewriting. 

Re French statistics for the occurrence of general paresis, 
Lautier found 27 cases in 426. Early in the war, Boucherot 
at Fleury received four cases of paresis among 107 cases; the 
majority of these, however, had not left the interior. Con- 
siglio in Italy received two cases out of 270. 

Re hemiplegia in this case, it may be inquired whether the 
hemiplegia which developed after the shell explosion on the 
same side of the body on which the patient had a true syphi- 
litic hemiplegia, was really syphilitic or not. Was it not, 
perhaps, in some sense psychogenic? A similar question may 
be raised concerning cases in which the locus minoris resisten- 
tiae becomes the site of symptoms. See Cases 409-414. 



SYPHILOPSYCHOSES 37 



Shell-shock: Hysterical blindness. Signs of 
cerebrospinal syphilis: Nevertheless, amaurosis 
functional. 



Case 29. (Laignel-Lavastine and Courbon, March, 
1916.) 

A soldier of the class of 1906 underwent shell-shock August 
13, 19 14, regaining consciousness 20 days later, but blind. The 
light of the shellburst, he said, was the last thing he had seen. 

For sixteen months, he was transferred from hospital to 
hospital, looked on sometimes as blinded; sometimes as 
feigning. Finally, on the isolation service of Maison-Blanche, 
December 15, 191 5, he received an ophthalmologists diagnosis 
namely, hysterical amaurosis. At this time there were found : 
stereotyped winking, with slight lachrymation, a slight left 
external strabismus, limitation in movement of all the ex- 
trinsic muscles of both eyes, especially to the right and in 
convergence and elevation; pupils slightly smaller than 
normal — and the general impression of a genuinely blinded 
or amblyopic subject. He seemed to be able to distinguish 
faint whitish spots, without contour or color, in objects 
brought to a distance of at least 40 cm. 

He also complained of bad feelings inside his head on the 
left side, and he proved to have a left-sided hemianesthesia 
of hysterical nature. There were no other sensory disorders 
and no reflex disorders. 

The nasolabial fold on the left side was flattened out, and 
there was also on the same side a slight diminution in the 
lower abdominal skin reflexes, and no response to plantar 
stimulation. Examination of the mouth showed leuco- 
plakia, and the history showed that the man's fifth child 
was born before term and died at two months. Lumbar 
puncture yielded lymphocytosis (55 cells) and an excess of 
albumin. The fundus examination showed a slight papillary 
disorder, suggesting a retrobulbar affection of the optic nerves. 

However, the preservation of the pupil reflexes seemed to 
indicate that nine-tenths, at least, of the amaurosis was 



38 SYPHILOPSYCHOSES 

functional. After mercurial treatment the headache grew 
less and the man was able to see somewhat better with his 
right eye. 

Laignel- Lavas tine and Courbon suggest that there was a 
dynamic disorder in this case, bearing the same relation to 
vision as mental confusion bears to the process of ideation. 
Analogous phenomena have been found in the sense of hearing, 
in such wise that the victims can, as it were, passively hear 
but do not listen. 

Re functional eye cases, see below, especially Cases 432- 
437. 



SYPHILOPSYCHOSES 39 

Shell shock (functional) phenomena in a syphilitic. 



Case 30. (Babonneix and David, June, 1917.) 

A marine, 26, on land service March, 1916, was buried by 
the explosion of a large calibre shell which killed most of his 
comrades. He remained for a time in a sort of lethargy. 
Coming to, he found himself victim of a right hemiplegia and 
deaf mutism, which phenomena vanished under electricity. 

In July, however, he had to be sent to a hospital on account 
of his sufferings, which received the diagnoses commotio 
cerebri, disorder of consciousness, disorientation, delirium, 
amnesia, over-emotionality. He was sent back to the front 
in December, 191 6, but promptly reported sick, with head- 
aches and insomnia. 

Examination showed nonorganic nervous disorders, con- 
sisting in a variable and patchy anesthesia of the legs, anes- 
thesia of the conjunctiva and pharynx, and over- reaction, 
with sighing, during the course of the examination. The 
organic signs were: exaggeration of tendon reflexes, equili- 
bration disorder, and incapacity to stand on one foot or 
execute a half turn or to stand still with eyes closed, and 
disorder of position sense. The lumbar puncture showed no 
cells, a slight globulin reaction, and an albumin titer within 
the normal. There was a leucoplakia and a positive W. R. 
The man was emaciated, febrile, and showed signs, with the 
X-ray, of bronchial lymph node disease. According to Babon- 
neix and David, the normality of the fluid indicates that the 
phenomena here were Shell-shock phenomena, despite the 
indisputable syphilis of the blood serum. 

Re occurrence of functional phenomena in syphilitics, 
Freud's remark may be recalled to the effect that a large 
proportion of his hysterics and other psychoneurotics are 
the offspring of syphilitics. 

Consider in this connection also Case 28 : an old syphilitic 
hemiplegia was followed by a probably psychogenic or hy- 
sterical hemiplegia on the same side. 



40 SYPHILOPSYCHOSES 

Vestibular symptoms in a neurosyphilitic. 



Case 31. (Guillain and Barre, April, 19 16.) 

A soldier, Colonial, 29, was twice in the 6th Army neuro- 
logical centre. The first time, February, 19 16, he was under 
observation for astasia-abasia, having been invalided twice 
for this disease, — once in 191 5. This man had had syphilis 
at 21, and was then taken care of at Saint-Louis Hospital and 
at Cochin. A volunteer for the duration of war, September, 
1 9 14, he had intermittent disorders of station and walking, 
which caused his invaliding January, 191 5. As the trouble 
stopped, he asked to go back to the front in September, but 
the same difficulty reappeared with fatigue, and he was sent 
to the army neurological centre. When standing, there was 
a ceaseless trembling of the whole body but especially of the 
legs, with tendency to propulsion. In walking also, there 
was a trepidant abasia, sometimes dizziness, and even a 
sudden fall. Standing on one foot he trembled and fell. 

Examined on his back, muscular strength was found in- 
tact in all limbs, and there was no trembling or incoordination 
or intention tremor in the performance of any movements, 
though there was a slight trembling of the raised fingers and 
hand. Reflexes were normal. The right pupil was dilated; 
the left pupil reacted sluggishly. There were lateral nystag- 
miform movements to the left. Caloric nystagmus appeared 
from the right ear in 15 seconds, from the left in 30. Rotatory 
nystagmus appeared in 35 seconds on both sides. Lumbar 
puncture yielded a fluid with a slight lymphocytosis; al- 
bumin, .3 grams; chloride, 7.30; sugar normal. 

Rest in bed improved the astasia-abasia, and the man was 
sent back to his corps, February 20, 191 6. He came back 
March 16, having had a dizzy spell, with suffocation feeling 
and a fall, whereupon the trepidant astasia-abasia had re- 
appeared. There were none of the so-called defensive re- 
flexes. The neuromuscular excitability of gastrocnemii was 
less on the right than on the left. A von Graefe sign was 
sometimes found ; no diplopia save on looking far to right. 



SYPHILOPSYCHOSES 4 1 

Lay reflections on syphilis : Suicidal attempts. 



Case 32. (Colin and Lautier, July, 191 7.) 

A man was called to the auxiliaries at the outbreak of the 
war, and served as stretcher-bearer at the Marne. He then 
became an attendant at the Grand- Palais. Acquiring gonor- 
rhoea, he was cared for but he grew depressed. The blood 
was examined and the W. R. found positive. The physician 
immediately made known the result without circumlocution, 
and knowing vaguely that the W. R. meant syphilis, the 
patient felt an irresistible impulse to suicide, and cut his 
throat. It seems that he had often before said that if he 
got syphilis he would kill himself. Recovering from his 
wound, he was invalided to Villejuif, Sept. 19, 1916, breath- 
ing through a cannula and responding to questions in writing. 
He had always been a nervous and emotional man, a farmer 
in Auvergne; he was married and the father of several 
children. 

Examination showed that the recurrent nerves had been 
cut and that the man must needs always breathe through the 
cannula. In point of fact, the W. R., only partially positive 
at the outset, did not indicate syphilis, and the gonorrhoea 
was now cured. But though the patient knew these facts, his 
hypochondria persisted, basing itself upon the suicidal wound. 
He said that his larynx had been stolen and he wondered 
why. He said that he had violent crises of suffocation, though 
there was, as a matter of fact, no difficulty with his breath- 
ing. Verdigris, he said, was forming on his cannula. Self- 
accusations about the suicide developed. On being trans- 
ferred to his department asylum, he made a suicidal attempt 
on the trip. 

Of course the gonorrhoea may have served as a partial 
factor in the genesis of the case, and his own mental attitude 
toward the contraction of syphilis may have been another 
factor. 



42 SYPHTLOPSYCHOSES 

The imitation of chancre. 



Case 33. (Pick, July, 1916.) 

A married German farmer, 32, was in Prague hospital in 
1908 during his period of military service and was then 
treated by inunction for a local chancre. He was given mer- 
curial injections a year later for rash. 

In 1912, he had signs of syphilis in the mouth. 

He was sent home from service in 191 3, with ulcers of hand. 

At the beginning of the war he was found to have ulcers on 
the knee, legs, and mouth, and was sent home for six months. 

Again called up in 191 5, the ulcers were still in evidence; he 
got inunctions in a military hospital four months. 

He was sent to his corps in July and had no relapse until 
July, 1 916, when he was detailed for active service. There- 
upon, ulcers began on the left hand and right leg. He re- 
ported sick, but was sent nevertheless to the front. In 
hospital he was found to have several scars about one inch 
across on each leg, on the dorsum of the left hand, at the 
right of the left index finger, and elsewhere. These scars 
were deeply pigmented. One of them was square! There 
were other recent ulcers that closely resembled tertiary ulcers. 
The most recent of these ulcers was angular, intensely red, 
and showed remains of a collapsed vesicle. There was a 
deep dark scab on the mucous membrane of the left cheek. 

There is no doubt that these ulcers were produced by some 
caustic, the nature of which remains unknown. The patient 
had, however, been able to evade military obligation during 
peace time and for two years during war time. 

Re simulation, according to Pick, some 5 to 7 per cent 
venereal diseases in the German army have been simulations. 
Gonorrhoea is simulated by soap, balanitis by cantharides, 
soft chancre by soap and mercuric or mercurous chloride 
mixed, hard chancre by a fluid or powder containing 
NaOH, Na 2 CO, and NaCl. Secondary syphilitic signs are 
imitated by cantharides or garlic, producing scrotal derma- 
titis. Tertiaries are imitated with caustics. 



SYPHILOPSYCHOSES 43 

Ramon to Rosina : a soldier's letter to his fiancee. 



Case 34. (Buscaino and Coppola, January, 191 6.) 

41 I am here to stay a month. Believe me, it is better 
here than in the army. There is a rule that we may eat 
as much as we can and everything is of the very best. 
The servants treat us like brothers. Do not think it 
is a nuisance to be inside four walls with a wee bit of a 
garden. No, indeed! But I have got to act the fool 
and from the very first day I began to play and act 
crazy with a kitten, so that if you had seen me you 
would say: " Ramon is really crazy." Rosina, dear, 
to avoid paying taxes you have got to be a smuggler. 
And now that I am at the ball I have got to dance. 
I want to see if after all the suffering I cannot get 
something better. I am better off here than at the 
regiment. I sleep in a fine warm bed, and they have 
only cold straw ; I have good food and drink and plenty of 
milk, and they have poor food and drink and so little. 

11 I expect to go home in about three weeks. I 
would have been there before if some fool of a spy at 
our place had held his tongue and minded his own 
business. At the same time, Rosina, dear, remember 
what I told you at Leghorn : that they had some officers 
sent there to get information and instead of going home 
they asked somebody else and were told that I had 
never been sick and had never had neurasthenia. 
When this information was got from the officers I was 
called to the office and they read to me that all that I 
had said and done was not true. I kept on acting the 
fool, and as they were still doubtful they sent me here, 
where there is a professor who passes me every morning 
in the garden and says: " How are you?" I always 
say: " I am the same, " acting like a crazy man. Let 
me tell you, Rosina dear, not to say anything contrary 
to this in your letters because they open and read 
everything in order to find out everything that happens 
and everything that is said. Now what you must do is 
to ask me how I am feeling, and whether my headaches 
are gone, and whether I have them all the time as 
formerly, and any other trifle that will help me." 

Rosina's fiance had a strongly positive W. R. in the serum. 
It was negative in the fluid. He was returned to the front. 



II. HYPOPHRENOSES 
(THE FEEBLE-MINDED GROUP) 



Moron of use at front (alienist's report). 



Case 35. (Pruvost, 191 5.) 

Vigouroux reports concerning a tanner of 19 who could 
not read, write or calculate (3 plus 8 equals 14) and had been 
of the 191 6 class in an infantry regiment at Brest, on the 
occasion of his asking to be sent to the front more speedily: 

Mental weakness, with insufficient school and theoretical 
knowledge but with the ability to assimilate practical ideas, 
though not knowing how to read, write or calculate; seems to 
have earned his living in several lines. "As a soldier, he 
does not know the insignia of the different ranks but under- 
stands how to obey a superior officer. Understands a gun 
and can tell a chargeur from a Le Bel gun. Moreover he 
seems to be perfectly stable, fixed in his wishes, persistently 
and intelligently wants to go to the front and kill Boches. 
He appears to be well disciplined and educable. Although 
feebleminded, he appears to us able to be useful at the front, 
though he should not be employed in any undertaking re- 
quiring initiative or foresight." 



44 



HYPOPHRENOSES 45 

An imbecile, superbrave. 



Case 36. (Pruvost, 1915.) 

A loquacious, active fellow, 22, with very slight school 
knowledge and no idea of military ranks (treated his superiors 
like his comrades) , was often punished in the barracks. He 
did not get on well with his instructors. His activities 
were never interrupted by any obstacles or by derision. 
He kept singing and talking enthusiastically during the mo- 
bilization. He was the butt of his section. 

At Dinant he did very well ; though his section was losing 
a good many men he remained calm. He was careless of 
danger and remained at his post firing ceaselessly at the 
enemy and giving a magnificent example to the few comrades 
who remained with him. In fact, he remained so long in his 
shelter that he was surrounded and taken prisoner. He 
escaped, swam the Meuse and got back to his regiment. 



An imbecile of service in barracks work. 



Case 37. (Pruvost, 191 5.) 

A farmer, 36 (father alcoholic, mother always sick, two 
brothers at the front ; patient had typhoid at an unknown age ; 
had gone to school at 13 but " learned nothing"; worked in 
fields with his brother who gave him some pennies on Sunday) , 
was put into the auxiliary service by the Council at 20. 
Patient said he was not strong enough for this service. In 1 91 4 
the Council reconsidered the case and put him into a regiment 
of infantry. He could not be given military instruction or 
execute the most simple drilling manual. He said that 4 
plus 2 equalled 7 ; 4 plus 3 equalled 5. He was of an excellent 
character, very docile and easily directed. He did all his 
comrades' barracks work and was very proud because, as 
he said, " I do everything they tell me to do." He was 
happy in working, everybody was good to him, but he had 
no comrades. He had no general knowledge and knew noth- 
ing about the war but that they were fighting the Boche. 



46 HYPOPHRENOSES 

Re imbeciles, Colin, Lautier and Magnac found amongst 
iooo soldiers entering Villejuif, 53 imbeciles. Twenty- four 
of them had been either exempt or retired at the outset of 
the war, when military surgeons had reviewed them and 
considered them fit for service. Several of the 29 others 
also had shown previous evidence of imbecility. 

Of course, French military surgeons may have felt that a 
number of these men would be of just such service in bar- 
racks and otherwise as Case 37 (Pruvost). But for one or 
two cases like Cases 37 and 41 of Pruvost, there are great 
numbers of other imbeciles who prove quite useless in the 
army. Two of the Villejuif cases had been volunteers: one 
volunteer declared that, if he had been intelligent, he never 
would have enlisted! Ten cases proved unable to use a 
gun; one turned his gun upon his mates. One regularly 
forgot the password. One (see Case 42 of Lautier) thought 
the war too long and tried to take command of the company 
in order to finish the war one way or the other. Three of 
the imbeciles had to be evacuated for desertion (unmoti- 
vated fugues); two of them cursed their officers. Some of 
the imbeciles had an emotional diarrhoea throughout their 
service. 

Colin suggests that line officers and military surgeons 
ought to agree that these men are not fit for service, and that 
the civil authorities of the home towns should advise the 
review boards about known imbeciles and criminals. In 
point of fact, previous knowledge of imbecility could have 
been obtained quite readily in 27 of the 53 cases observed 
by Colin, 



HYPOPHRENOSES 47 

A feeble-minded inventor. 



Case 38. (Laignel-Lavastine and Ballet, 191 7.) 
A jockey of Nimes, 31, entered the service May 15, 1917. 
He retired before the war. He was in the auxiliaries at the 
moment of mobilization. Nothing is known as to any patho- 
logical episodes in his past. He said he had been a poor 
scholar, had left the primary school at eleven hardly knowing 
how to write or spell, but he had a lively imagination and was 
a happy-go-lucky youth, playing many tricks on the trades 
people. He tried a variety of ideas in the industrial or com- 
mercial world with very varying success. He had a mechani- 
cal taste. The Colonial Exposition at Marseilles caused 
him to float a variety of projects, from that of having the 
visitors photographed on a camel to the sale of lemonade. 
He said he had been a jockey and then a trainer and had 
finally become a valet de jockey at Maisons Laffitte. He was 
a gambler and invented a " system." He made various 
inventions in relation to horses. At the end of 19 14 he had 
plans for a bomb thrower and placed his discovery at the 
service of the War Minister. He was not discouraged by the 
lack of success of the bomb thrower. He now made an 
aerial torpedo carrier. He had the idea of the tanks. 
However, he found the secret of his torpedo carrier printed 
in a magazine. There was a slight difference between the 
German apparatus and his own. 

From this time he began to be mistrustful, and now he 
jealously avoided entering into any details about his inven- 
tions and he did not let his officers see his plans. The Com- 
mandant offered to give a place in the safe to his documents, 
but he could not embrace the offer. He now invented a 
counter-torpedo machine. He went on leave to Paris, asked 
an audience of the Minister of Marine, who put him in 
relation to the Committee on Inventions, who put him off, 
desiring that he should forward all his plans. He emerged 
from one of his interviews so excited that there was a scandal 
on the public street and the police commissary evacuated him 
to Val-de-Grace, but the patient says he does not remember 



48 HYPOPHRENOSES 

this incident. He came on service of Laignel-Lavastine 
May 15. He shortly wrote again to the Minister, who 
again referred him to the Committee on Inventions. He 
protested to the President of the Republic and wrote directly 
to the King of England, who referred him to the Military 
Administration. He is now occupied in creating a machine 
to destroy the first line trenches and continues to write to 
the Ministry. He has documents buried underground in a 
secret place. He still talks with great vivacity of his dis- 
coveries. 

According to Laignel-Lavastine, we deal with a feeble- 
minded person who has for many years had a delire raison- 
nant of the inventing group. 

Re feeblemindedness in the British Army, Shuttleworth 
found 70 who had joined from special schools for the feeble- 
minded in London, and 100 from Birmingham in the year 
19 1 5. The institutional "children" were in general good at 
drilling and obeying. One of them, given to lying and 
stealing, got into constant trouble in Flanders. 

Sir George Savage stated that he had sometimes run the 
risk of allowing enlistment of men who had shown earlier 
in life a weakness for lying and pilfering, and remarked that 
such men might make good soldiers. A case like the above 
(38) would run counter to this view. On this matter, see 
below Case 183 (Henderson), one of pathological lying. 



HYPOPHRENOSES 49 

An imbecile who walked lame. 



Case 39. (Pruvost, 191 5.) 

A soldier, 20, eight days after being called to the colors, 
complained of pain in the knee and hip. He was observed 
for 18 days in hospital and then sent back to his company; 
but he continued to complain of the pains, and the regimental 
surgeon sent him to a neurological center where the joints 
were found to be normal and where no sensory, motor or 
reflex disorders were in evidence. The man continued to 
walk lame and insisted he could not get about without a 
cane. He also complained of his mouth and his belly and, 
though he was very ruddy, said he was a bout de forces. 

It was a question of simulation. The man, however, was 
a feebleminded person who could not read, write or calculate. 
He was invalided as such. 



Enlistment to improve character. 



Case 40. (Briand, February, 1915.) 

A village boy had passed for simple ever since typhoid 
fever at 8. He had learned to read and write, but had always 
been impulsive and subject to fugues, running to see his 
grandmother, or off as a truant. It was decided that he, at 
19, should enlist to improve his character. But one fine day, 
even before the war, he deserted. He said, in explanation, 
that he had lost his way, and he was being examined mentally 
when mobilization began. 

He looked ape-like, with spread ears; had a low forehead, a 
head flattened behind, an asymmetrical face, prognathous 
jaws, an arched palate, and defective teeth. He talked freely 
of homosexual relations, and said he wandered off because 
it occurred to him to do so. He was determined to be unfit 
for service. 



50 HYP0PHREN0SES 

An imbecile who may be sent to the front. 



Case 41. (Pruvost, 1915.) 

A Parisian sandwichman, 25, of unknown parentage and a 
state ward, placed out with a armer at 12, escaping with a 
friend to Bordeaux at 14, thence leading a wild, improvident 
life at Lyons, Marseilles and Paris, sleeping in fields and 
hedges, earning 22 sous a day but in no case mixing with the 
police, was examined for physical inefficiency at 20 years. 
He wanted to enlist but was refused. He insisted and was 
very proud of the fact that he got in as the Major said 
to them, " Let him go in." He could hardly read, write or 
calculate but was by reason of his adventurous life full of 
practical resources. He was irascible and frequently crimed, 
whereupon he would cry under the Captain's window, " Rob- 
ber band, idiots, I shall write to the Minister." He was 
passionately fond of military life, though he had but the 
vaguest notions about the commands, the names of generals 
and the like. He wanted to drill. His comrades played 
practical jokes upon him asking him to look for a trajectory, 
for the squad's umbrella and the key to the drill ground. 
They also told him he had been proposed to be corporal, 
whereupon he was greatly overjoyed and immediately sewed 
stripes on his sleeve and began to give commands. He said 
if they put him among the auxiliaries he would throw the 
adjutant in the water. He sang and swung his gun with 
joy when he went to the front. He thought there were stripes 
hanging to the barbed wire and wanted to pick as many 
as possible. Such a man may be safely sent to the front 
although he will bear watching. At the date of report 
this man had been at the front two months doing very well. 

Re the comparative success of the Germans in the matter 
of excluding imbeciles, Meyer found that 8 per cent of the 
mental cases in the army were cases of mental defect. 



HYPOPHRENOSES 5 1 

Imbecile with sudden initiative. 



Case 42. (Lautier, 1915.) 

A soldier, 41, a farmer, from the Department of the Marne, 
married, childless, was called to the colors August 31, 1914. 
He was on guard duty until May, 19 15, watched prisoners 
until October and was finally sent to the front, February, 1916, 
where he fell sick. 

" He was tired in his head." " His commanding officer 
made him drill without rhyme or reason ; he would have been 
able himself to have commanded with greater intelligence." 
He once attempted to put himself at the head of the company 
to lead them against the Boche ; this idea arrived to him all of 
a sudden in a phase of perfect confidence and sang froid. He 
thought his comrades would follow him and that the officers 
would do likewise. He hoped thus to be able to end the war 
one way or the other. He was getting tired of the war and 
regretted his family life and kept saying that this was no 
existence for family men. " We ought to attack or ask for 
peace." No one followed him and his comrades said he was 
un peu fou but he did not share this opinion. 

In point of fact he hardly knew how to read or write and 
at home lived with his relatives, submitting himself entirely 
to their guidance. He was much afraid of being punished and 
often feared that he had done badly as he had trop de con- 
science. He was non-alcoholic and without hereditary or 
acquired neuropathic taint. He had no pronounced stigmata 
of degeneration. He was rather reticent about certain 
mystical ideas of a political tinge. At Villejuif, whither he 
was brought February 17, 191 6, he received a diagnosis of 
imbecility. 



52 HYPOPHRENOSES 



Emotional fugue in a subnormal subject. 



Case 43. (Briand, February, 1915.) 

A soldier in the Territorial Army, 40, appeared before 
the examining board in a depressed, dejected-looking state, 
speaking slowly but collectedly and lucidly. Mobilized the 
second day, this man was much afraid that he could not 
get through the marches, and asked for a special examination 
to determine whether his feet did not make him unsuitable 
for fatigue. Two physicians thought he was unsuitable for 
marching, and another thought he put it on. A trial march 
was not executed well. He was kept in barracks but jumped 
the wall, put on civilian clothes, and made off for Paris. But 
a relative, warned by his wife, finally got him to go to the 
authorities. He was told that he ought to return in the 
afternoon, when suddenly he was arrested. 

It seems that the man relied on the opinion of the two 
physicians and discounted that of the third. He thought 
himself the victim of an injustice, and not knowing how to 
get on, it occurred to him that he would abandon the regiment 
and get out of the difficulty. It was without resistance, how- 
ever, that he gave himself up as a prisoner. This fugue was 
neither unconscious nor amnestic, nor was it due to an ir- 
resistible impulse; nor can we say that it was due to a 
genuine intellectual disorder. It was an emotional fugue, and 
partly due to the man's long-standing depression. It seems 
that he had inherited this character from his father. He 
was below normal intelligence, had a very poor education, 
lost his wife, and grew more and more sombre. He married 
again, but this time a neuropath. He began to be preoc- 
cupied with his health and he had even some ideas of suicide. 
At the time of his leaving the regiment, he had passed through 
a phase of depression of about 6 months' duration, and at 
this time had a number of hypochondriacal ideas with poor 
appetite and loss of weight. 



HYPOPHRENOSES 53 



Diagnostic dispute between regimental surgeon and 
alienist. 



Case 44. (Kastan, January, 191 6.) 

Julius Q. was sent on guard April 14, 191 5, with orders 
to remain there. While on guard he made a noise and made 
a movement as if to take a knife from his pocket. Ordered 
to empty his pockets, he attacked the other guards. The 
witnesses said that he was drunk. 

Upon examination, it appeared that he had recognized and 
called by name those present in the guardhouse, despite his 
supposed intoxication. There were red spots on the skin 
and a certain amount of analgesia. His powers of compu- 
tation and reasoning were poor. He was unable to explain 
the meaning of a picture shown him. He maintained that 
he had an indomitable desire for drink. A diagnostic draught 
of alcohol yielded no reaction. Upon dismissal, he got drunk 
at once again, and had again to be imprisoned in a state of 
excitement. What the outcome in this case was is not stated 
by Kastan. 

The previous history seems important. Julius Q. had been 
a state ward. He had escaped several times from the in- 
stitution but had always to be brought back again because 
he could not be trained at home. He had once attacked a 
supervisor in the state institution with a knife. It seems 
that he had at this time been drunk, having been brought 
back drunk to the institution. 

Two years before the war he had been taken to the Breslau 
Hospital for the Insane on account of fits of insanity. In 
19 1 3 he had been a patient in Wuhlgarten on similar grounds. 
The diagnosis there had been epileptoid degeneration, psy- 
chopathic constitution, imbecility, or epilepsy(P). He had 
been convicted of crimes a number of times and put to 
labor. He had been given to cruelty in childhood. 

Despite this, he was declared perfectly healthy in mind and 
body by the regimental surgeon. 



54 HYPOPHRENOSES 

In 1914, Q. fell suddenly ill in prison (he was presumably 
in prison for a military offence), and smeared the cell with 
feces, saying that he was able to do that as he could pay for 
anything. He stared at the floor and failed to answer ques- 
tions. He remarked, however, that he had frequently been 
convicted for breach of the peace and assault and battery, 
and he said his father had been a drunkard, and he acknowl- 
edged hallucinations to the extent of saying that he heard his 
name called when he was alone. 

The story of this case warrants our inquiring why such a 
patient was kept in the army. He was kept there clearly 
on account of the report of the regimental surgeon, who 
could not have taken seriously the previous history of the 
case, or else thought the patient perfectly good cannon fodder. 

The hypothesis of syphilis apparently need not be en- 
tertained. That of feeblemindedness is possibly the funda- 
mental diagnosis, yet epilepsy was considered by the German 
diagnosticians, doubtless on account of the sudden violent 
attacks and breaches of peace on the part of the patient. 
There is clearly something behind mere alcoholism in the en- 
tire story of this state ward. On the whole, the periodicity 
of the attacks is equally consistent with the picture presented 
by numerous feeble-minded persons, and the institutions that 
had to deal with Q. regarded him rather as epileptoid. 
There seems to be evidence of actual intellectual defect. 
Accordingly it seems wiser to consider the case of Julius Q. 
one of feeblemindedness, possibly of the moron group. We 
should then consider the epileptoid features as part and 
parcel of the feeblemindedness. We should consider the 
intellectual defect a part of the process ; and the uncontrollable 
impulse to drink, the sudden violent attacks, and the cruelty 
in childhood would then be regarded as merely symptomatic 
of the feeblemindedness. It seems clear that either mental 
tests by the regimental surgeon or an examination of the 
patient's previous history would tend to exclude such a 
patient from the army. 



HYPOPHRENOSES 55 



How can a rifleman be an imbecile ? 



Case 45. (Kastan, January, 1916.) 

Anton K. was down in the list as " missing." He was 
found at home. He said his feet had become sore from the 
marching. He had lain down and become unconscious. 
Coming to his senses, he was possessed only of trousers and a 
shirt but he got a civilian suit in a village. He had gone home 
part way by train, part way on foot. It seems that he did 
not tell his father any details about his coming back although 
he expressly denied deserting. 

It seems no mental weakness had been noticed in the army. 
It had been observed, however, that after seeing the first 
corpses he was deeply impressed and did not want to see any 
more. On examination in the hospital he gave the impression 
of indifference and low spirits. He had to be urged to eat 
and work. No great amount of intelligence defect could be 
determined, though his knowledge and capacity were below 
the average. The physician examining him thought his de- 
pression was either caused by or increased by his imprison- 
ment; but this examiner thought that the protection of 
Section 51 did not extend to the patient at the time of his 
desertion. The examiner thought that an examination by a 
psychiatrist was not necessary, though both judge and 
prosecutor urged it. 

When examined in the clinic, he seemed to be disoriented 
for time. He claimed to have been able to stand the shoot- 
ing and the sight of the corpses. After becoming unconscious, 
he had wakened and eaten cucumbers and carrots in the 
fields, wandering on for a period of three or four weeks, 
until he came to a place where he had formerly worked. 
The reason he had thrown away his uniform was because 
Russians had been about. He had not known that it was his 
duty to report to the army again. 

It was found that the patient's father was poorly developed 
as to mind, that his brother was subject to periodic mental 
disturbance so that he had to be watched. It was found 
also that K. himself had had a similar mental disturbance, 



56 HYPOPHRENOSES 

lasting a week, two years before. Moreover he was not 
considered mentally right in his home town. In fact, no 
one there wondered really at his desertion because he was so 
stupid. His school work had been poor and limited. 

He himself said that his people were of sound mind; that 
during school days he had felt bad in his head, once running 
into the woods after being told something. He was able 
to give the names of his former superiors. His calculations 
were only partly correct. He was poor at reasoning and at 
simple distinctions ; for example, asked the difference between 
a bird and a butterfly, he replied that a butterfly was a bird 
too. He did not know the difference between a river and a 
lake. He thought Russia, England, and Austria were the 
enemies of Germany. 

He sat about or lay on the floor, motionless and indifferent, 
with a newspaper stuffed into his trousers, unoccupied al- 
though saying that he wanted to work, and even allowing 
his fingers to be burned by cigarettes he was smoking. 

He was tried once more and the first medical expert still 
adhered to his former opinion, pointing out that K. was a 
rifleman and that only an intelligent man could be a rifleman. 
The court, however, accepted Kastan's opinion and granted 
K. the protection of Section 51. 

In comment upon this case, it seems clear that ever so 
slight a knowledge of K's home town reputation would have 
naturally excluded him from the army. However, what is to 
be said " when doctors disagree,' ' as noted by Kastan in this 
very case? It seems impossible, also, that his comrades 
should not have noticed something odd about him (over and 
above the deep impression on seeing the first dead) which 
might have given occasion to the regimental surgeon for a 
special mental examination. However, to the military mind, 
mayhap the man seemed to be sufficiently " effective. ,, 

Re imbecility in a rifleman, the compiler has studied some- 
what elaborately the brain of a feeble-minded murderer with 
some North American Indian blood in him. This man was 
a crack shot despite his subnormality. It would seem that 
the German regimental surgeons castigated by Kastan as 
above were very properly so castigated. 



HYPOPHRENOSES 57 

Hypomania in an imbecile. 



Case 46. (Haury, August, 191 5.) 

A brusque little man, of a somewhat bold and talkative 
disposition, though giving a good first impression, was evi- 
dently a bit feebleminded, though (as Haury says) of the ac- 
tive group. He had a sister like himself, whose children were 
taken care of by the State, and at home he had had a number 
of fugues, about which details were lacking. It was soon 
evident what sort of soldier he would make, and he was put 
in one of the Territorial regiments, but it was not noted that 
he had a genuine mental disorder, as he was thought to be 
just a peculiar person. 

His new relations caused him to do a number of eccentric 
things. He shortly proved to be in a sort of rudimentary 
maniacal state; talkative, restless, scheming rather feebly to 
go back to his village. He said that he couldn't walk on 
account of corns, and that these corns required a certain drug, 
which he wanted to get from home. He said that he had 
been struck by lightning twice ; that he had fires in his body, 
etc. He wanted only to be retired on a pension of one or 
two hundred francs so he could take care of his farm, his hay 
and his fields. There was no need of trying to get land by 
means of bullets, he said, since he had enough. 

The mental disorder of this man was much deeper than 
appeared, and in fact, he did a number of dangerous things 
compromising the security of the entire regiment. 

Re the dangerous tendencies of Case 46, see the remarks 
above drawn from Colin, under Case 37. 



58 HYPOPHRENOSES 

Insubordinate desire to remain at the front. 



Case 47. (Kastan, January, 191 6.) 

Friedrich L., on March 4, 191 5, was ordered to go back to 
the baggage- train. He did not obey. He said to the non- 
commissioned officer who then came to him, "I am not 
going; you have nothing to say anyhow, you ox- tender!" 
He stood with his hands in his pockets, and, when the officer 
seized him angrily by the collar, L. struck the officer's face. 

He stated at his hearing that no one had the right to send 
him back. At that time even he conveyed the impression of 
being not quite normal and was let off with his arrest only. 
Later he refused again to go on guard duty, saying, "You 
have nothing to say at all. Perhaps you will find out that 
we shall meet each other again in hell tomorrow morning." 
He was taken before the physician, who considered him 
mentally inferior and not entirely appreciative of the nature 
of his acts. He was told that the death penalty would meet 
such behavior, whereupon he remarked, "I am not afraid of 
the death penalty," staring excitedly at the officer and trem- 
bling throughout his body. It seems that he had already 
made an impression of mental inferiority in the troop, and 
had once before said to an officer who wanted to send him to 
the front, that he would not go; this had been regarded as 
almost a breach of discipline. He had been in the habit of 
not reacting to the calls of his superiors, and had smiled at 
their reproaches. He seemed to hold the opinion that not 
even a company commander had power to order him to go 
back. Examined in the clinic he held to the same opinion, 
that there was no need of his going back; that they took 
volunteers; and that he wanted to remain at the front. On 
the day of the deed, he had drunk a rye whiskey. He had 
shaken off the non-commissioned officer because the leader 
had seized him by the throat. In the clinic he often smiled 
and wrinkled his forehead. He gave evasive and inadequate 
answers. Asked about oaths and perjury, he remarked, 
"I prefer to remain silent." 



HYPOPHRENOSES 59 

He said that one of his sisters was a little stupid. Study 
of his previous history indicates that Friedrich L. had for- 
merly been a quiet and steady man, although he often had 
attacks of rage, breaking out upon sudden excitements. As 
to his capacity in school, nothing could be learned, since the 
Russians had taken the school registers away. 

The analysis of this case seems to reduce to the question 
of feeblemindedness and schizophrenia, unless some form of 
inborn qualitative inferiority of mind be preferred as the 
diagnosis. On the whole, possibly, the diagnosis of feeble- 
mindedness seems preferable. The entire symptom picture 
seems to relate to the patient's one mental attitude about 
sticking at the front, ruat coelum. 



60 HYPOPHRENOSES 

A French soldier who admired Germans. 



Case 48. (Lautier, 191 5.) 

A man with the extraordinary first name of Agapiihe 
(Laurent insists on the frequency of strange first names in 
degenerate families) came from Val-de-Grace to Villejuif 
June 5, 1 91 6, with the diagnosis of mental weakness, interpre- 
tative ideas of persecution, mental excitement, recrimination, 
logorrhoea, and a tendency to revengeful reactions. 

On arrival the patient said he must be in an insane asylum 
because he heard spiritiques talking together. He, however, 
was "not insane" and began expounding his plans for re- 
venge with the words "Kill," "Cut- throat." 

This man had been placed in the auxiliary service by the 
Council, called to the colors December 13, 1914, and finally 
sent to the front in May, 191 5. In July he was made pris- 
oner in a brush. He said, "I cried out, * Comrades, what 
difference does it make to me whether I am German or 
French? My officers are imbeciles that drink the blood of us 
unlucky ones! ' " He was interned in some camp whose 
name he could not exactly give and reported that the Ger- 
mans were very gentle with him, that his real enemies were 
the French, for the French were against him night and day. 
"As a matter of fact, among Germans the French are noth- 
ing but cochons malades. The Germans are fine types." 

He was repatriated in May, 19 16. He kept making ver- 
bose and neologistic eulogia of the Germans. He had been 
a farm boy in Brittany, where he had had headaches. He 
had been at Quimper Asylum in 1 910. In fact, he said his 
parents had tried to poison him and to have him assassinated ; 
they had charged him with setting fire to their house. His 
mother was an imbecile, he said, who believed she was the 
Queen of France. His recriminations did not stop short of 
himself. He had been accused of kissing a girl and stealing 
apples ; as a matter of fact he knew what to do with girls. 

He had a coarse face and a number of stigmata besides his 
name Agapithe. He was kept at Villejuif as an imbecile. 



HYPOPHRENOSES 6l 

Unfit for service : Question of feeblemindedness. 



Case 49. (Kastan, January, 1916.) 

Walter N. was declared unfit for military service in 191 2, 
on the ground of mental incapacity. He had shown this 
clearly during his period of training. He committed a num- 
ber of slight offences secretly, but not so secretly but that 
they were immediately discovered and punishment meted 
out therefor. He could do nothing without aid. It appears 
that his mental weakness had not been noticed in school, but 
that his employers had thought him both feebleminded and 
irresponsible. Nevertheless he always executed orders prop- 
erly. While in hospital in 191 2, he had occupied himself 
very little, sitting indifferently, quiet and dreaming. At that 
time, he had shown poor calculating ability and decreased 
power of perception. It also appears that he did not grasp 
the nature of simple orders, the requisite associations being 
disturbed. 

Despite this history, on September 1 1, 1914, he found him- 
self being transported. He claimed to be very tired. Upon 
reaching the city, he picked up a large stone and raised his 
arm as if to strike the transport leader. While N. was being 
bound by the transport leader in consequence, he kicked at 
his leader's shins. 

In the clinic he resisted examination, moving his legs 
without speaking, staring at the floor, moaning frequently, 
sitting motionless with head hanging, answering monoton- 
ously repeated questions, but turning his head at a loud 
noise. He felt ill. It appeared that he was oriented and 
that his knowledge was well preserved although his calcula- 
tion ability was poor. 

It would seem that psychiatric examination, possibly with 
the aid of psychological work, would have excluded Walter 
N. from the army. 



62 HYPOPHRENOSES 



Oniric delirium (Regis) in a somewhat feeble- 
minded Esthonian. 



Case 50. (Soukhanoff, November, 191 5.) 

An Esthonian, 21, a soldier in a reserve regiment, came to 
a psychiatric section towards the close of 19 14. He was 
negativistic, mumbling, restless, fugacious; later more tran- 
quil. One day he entered the physician's office, walking up 
and down, mute, looking at articles and attempting to take 
them away. 

February 21, 191 5, he was evacuated to the Notre Dame 
Hospital for the insane at Petrograd, — a tall, healthy, 
agitated-looking youth with a rapid pulse. He explained in 
poor Russian how he was now among Germans and feared 
that they were going to hurt him. At first in the hospital 
he was seclusive and morose. March 9 he became excited, 
and tried to break through the door. He was placed in the 
bath, agitated and yelling. An Esthonian interpreter did 
not quiet him. The Germans were going to make a martyr 
of him. After an hour of this he grew quieter, and next day 
complained only of head weakness and malaise, was in good 
humour, smiling, and reading an Esthonian paper, and well 
behaved in church, though tired and pale. 

He now got better, began to work and wrote letters. It 
seemed as if he had waked up from a painful dream. He 
explained how he though he had been in captivity; that 
he was going to be hanged. He had thought that the Ger- 
mans could talk Russian. He had had hard work in his 
regiment, as he did not understand Russian and had never 
before left his little village in Livonia. His mental disorder 
had started in the autumn, but all that was now like a dream. 
He said that he had had a mental disorder of short duration 
following some bodily disease, at the age of thirteen. Ac- 
cording to Soukhanoff, this is a case of Meynert's amentia, 
in a somewhat feebleminded person. The twilight state 
might well receive (according to Soukhanoff) the term "oniric 
delirium " invented by Regis. 



HYPOPHRENOSES 63 



Shell-shock; burial: Incapacity to rationalize the 
situation. 






Case 51. (Duprat, October, 19 17.) 

A soldier, 39, a herdsman, was shell-shocked at Hill 304 
May 23, 1916, buried twice, slightly wounded in right eye, 
and carried unconscious to Bar-le-Duc. He was then forty 
days in a semi-confusional state with headaches and dreams 
of the Boches wanting to behead him. Some of these dreams 
came in the waking state, in which state he could recognize 
them as imaginary. In April, 191 7, he said he had always 
been afraid, even in daytime, that he would be hurt and had 
been especially troubled by the fear of shells. He was also 
bothered by nocturnal enuresis which might become an in- 
curable disease and bring impairment of memory and atten- 
tion. Although not feebleminded the man was of but mod- 
erate intelligence, and his emotions, according to Duprat, 
were such as to defeat any complete resolution of his plight 
by the intellect. 

An affective complex, passing from the surprise of the shell- 
shock over to a fright based on clear though wrong ideas of 
what might happen to him, had left him without sufficient 
power of autocritique. 



64 HYPOPHRENOSES 



, 



Weakling, twice buried by shell explosions in one 
day: Change of character; fear; three fugues ("It 
is stronger than I am"). 



Case 52. (Pactet and Bonhomme, July, 191 7.) 

An infantryman, Class of 191 3, at the front from Sep- 
tember, 1 9 14, had a somewhat infantile build physically but 
was intellectually of average powers, having been a type- 
setter (three years in a job). However, the confined life had 
borne hard upon him and his father put him on a farm. He 
passed through his military service successfully, though he 
was given two weeks in the guardhouse for overstaying 
Easter leave. He was suggestible enough at this time to 
think that he would not be punished very severely, since 
there were other men whose leaves did not expire at the same 
time as his own. 

He was buried twice in the same morning, March, 191 5, 
at Bois Le Pretre, spent four or five days in hospital, and 
went back to his battalion. But now there was a change in 
his character. Formerly indifferent to danger, he was now 
apprehensive every time he went to the line and felt an 
almost irresistible impulse to make for the rear. He was 
condemned to five years in prison, June, 191 5, but was 
finally sent back to the front. 

However, in July he left his company a second time as it 
was going into the trenches, and this time the captain simply 
asked him to do better. A third fugue, a few weeks later, 
sent him back to court-martial, and thence to be examined by 
alienists. He was perfectly conscious at the time of the fugues 
and understood his duties and possible punishments. All he 
would say was, " It is stronger than I arn." Fear outweighed 
every consideration after the episode of the shell burials. 

The man may be regarded as a hypobulic, somewhat feeble- 
minded person, able to get on in civil life but thrown out of 
gear by war. Of course, the concept of fear as a disease can 
easily be overdone ; however, here was a case in which three 
desertions occurred; the third after severe punishment. In 
the differential diagnosis, epilepsy, alcoholism, impulsive 
poriomania, must be considered, as well as feeblemindedness. 



III. EPILEPTOSES 
(THE EPILEPTIC GROUP) 



Diagnosis " epilepsy " revised to neurosyphilis. 



Case 53. (Hewat, March, 1917.) 

A Scotch soldier, in the Royal Navy, 43, was admitted to 
the Royal Victoria Hospital at Netley, as major epilepsy. 
He had been 12 years a stoker, and 16 years before admission 
had suffered from syphilis, a chancre locally treated with 
black wash, without secondary rash. 

After leaving the Navy, he had worked in a fire-brigade 
and as dock laborer. He had been very alcoholic when funds 
permitted, although never "primed." His first convulsive 
seizures came at 40, while working at the docks, following a 
night on which he had drunk a bottle of whiskey. He 
thought he had been about half an hour in the fit. 

He joined the A. S. C, January, 1915; served in France; 
later at Salonica. He had eight convulsive seizures, some 
in France, and others at Salonica, always after much rum. 

The man was tall, powerfully built, without visceral dis- 
ease, speech defect, or other symptoms except that both 
pupils showed the typical Argyll- Robertson phenomenon. 
The deep reflexes of arms and lower legs were increased. 
The superficial reflexes were diminished, and the Wasser- 
mann reaction strongly positive. A seizure was observed 
by Hewat and the diagnosis of major epilepsy was revised. 
The diagnosis of cerebrospinal syphilis, non-paretic, was pre- 
ferred to that of paresis on account of the absence of all the 
ordinary symptons of paresis and of tremor. It might be 
asked whether these fits were chiefly alcoholic in origin. 
However, the patient had two or three fits while in hospital 
during a period of eight teetotal weeks. Hewat remarks 
that the case suggests that the serum of any patient develop- 
ing epileptiform seizures for the first time say between 35 
and 50 years of age, should be given the Wassermann test. 

65 



66 EPILEPTOSES 



Syphilis may bring out epilepsy in a subject having 
taint. 



Case 54. (Bonhoeffer, July, 1915.) 

A man of 35 in the Landwehr acquired syphilis some time 
in the summer of 19 14. He was a good soldier, passed 
through several clashes, and was promoted to Unteroffizier. 

To understand what followed it must be stated that he had 
been a bed- wetter to 11, had been practically a teetotaler 
(Bonhoeffer's point is perhaps that otherwise epilepsy might 
have developed sooner?), and, when he did drink, vomited 
almost at once, and had amnesia for the period of drunken- 
ness. His father drank. His sister had fits as a child. 

February, 1915, the Unteroffizier lost appetite, got head- 
aches, and went to hospital for a time. Upon getting better, 
he was sent on service to Berlin. In a Berlin hotel he had 
his first convulsions and unconsciousness, biting his tongue. 
He was confused for several days, and, when he had become 
clear, had a pronounced retrograde amnesia together with a 
tendency to fabricate a filling of events for the lost period. 

This retrograde amnesia is uncommon in epilepsy and 
suggests organic disease. No sign of such was found, or 
signs of the epileptic make-up. The serum W. R. was 
negative. On the whole, Bonhoeffer regards the epilepsy as 
" reactive " to the syphilis, as a syphilogenic epilepsy. 

Alcoholism caused amnesia in this man in the same way as 
the syphilitic epilepsy now did. 

Re epilepsy and syphilis, Bonhoeffer states that he has 
repeatedly seen syphilis giving no other symptoms than epi- 
lepsy develop in the campaign. At the same time, Bon- 
hoeffer does not find that the incubation period in paresis 
can be shortened by war factors; at all events, by the ex- 
haustion factor in war (see Case 25). It might be questioned 
whether the above case (54) was not psychogenic; that is, 
whether the syphilis did not act in combination with being 
sent to Berlin on service as a psychic factor. However, this 
epilepsy on the whole seemed not psychogenic. 



EPILEPTOSES 67 



Syphilis in a psychopathic subject. Convulsions 
5 days after Dixmude. 



Case 55. (Bonhoeffer, July, 1915.) 

A soldier in the reserves, 23, was, subsequently to his 
being brought to hospital, described by his wife as a rather 
over-sensitive fellow, who could hardly look at blood and 
was meticulous about the household. He had always been 
subject to headaches, especially after hard work. How- 
ever, he had passed through his military training well in 
1 910, not even having been bestraft. 

He began service in October and fought at Dixmude on 
the 19th. On the 24th in the trench and while being carried 
back, he had several spells of pallor, falling stiff, and then 
having convulsions. Brought finally to the Charit6 in Berlin, 
he had more spells of sudden pallor, collapse with brief con- 
vulsions, tossings in bed, as well as absences, post-convulsive 
headaches, and mild bad humor. 

There were numerous attacks several days apart in the 
first seven weeks. The patient was not of an "epileptic" 
disposition, though readily dissatisfied and headachey. 

The serum W. R. was positive. Treatment by mercurial 
inunctions. No further convulsions. Prognosis doubtful. 

Re epilepsy and the war, during the first six months 
Bonhoeffer observed 33 cases in the Charite Clinic in 
Berlin. Twenty of these 33 cases, unlike Case 55, had 
attacks before the war, although ten of these had become 
epileptic rather late, namely, after the period of active mili- 
tary service, at ages from 22 to 27. The development of 
epilepsy like Case 55's is not without frequent precedent. 

Bonhoeffer states that aside from epilepsy directly due to 
brain injury by shells, there has been no certain case in which 
we have the right to regard the war itself as the total cause 
of the epilepsy. Some, like Case 55, are of syphilitic origin. 
No subject with a severe long-standing epilepsy has been 
able to get into the field, according to Bonhoeffer; when 
they do, they prove constitutional subjects. 



68 EPILEPTOSES 

An epileptic imbecile, court-martialed. 



Case 56. (Lautier, 191 6.) 

A Belgian soldier was condemned by court-martial Feb- 
ruary 27, 1 91 5, to five years imprisonment for leaving his 
post in the presence of the enemy. It seems that he was 
mounting guard with two of his comrades and all three left 
to eat as no food had been brought to them. 

A physician examined the Belgian soldier and declared 
him responsible, although a little sick. All three were con- 
demned to imprisonment. The Belgian attracted attention 
in prison through crises of anxiety and agitation; he had 
terrible nightmares, seeing Germans in his cell and hearing 
gunshots. He was accordingly sent to a special infirmary 
of the depot, whence July 24 to Sainte-Anne, July 26 to 
Villejuif. He talked Flemish, hardly understanding French, 
and spoke slowly and with difficulty. He hardly knew how 
to read or write. He had been a truckman. 

At 18, this soldier, according to his own account, began to 
have nervous crises in which he fell, lost consciousness, bit 
his tongue, foamed at the mouth and urinated involuntarily. 
The attacks were somewhat rare. His father sent him in 
1 9 10 to Gheel where he stayed two years. Returning home 
he helped his father in the trucking work. 

When the Germans came the family fled to France and, 
about the end of 1914, he was put into the military service 
and sent to the front after a very short period of instruction. 

The man had followed the example of his two comrades 
without taking the slightest thought. He did not under- 
stand the gravity of his act. He was not remorseful, re- 
gretful or angry against his judges. He was well oriented 
but quite indifferent. He was a tall, intelligent looking man 
with adherent lobules, slight facial asymmetry and evidence 
of tongue biting. He wrote like a child and read slowly, 
spelling out the complicated words. He was employed at 
various manual tasks during his sojourn at the asylum and 
had no epileptic attack. He was given over to the Belgian 
military authorities October 5, 191 5. 



EPILEPTOSES 69 

Seizures in a feebleminded subject — psychogenic 
components. 



Case 57. (Bonhoeffer, July, 191 5.) 

A 2 1 -year old tailor, unused to marching, went into the 
field in August. A month later, after a period of long stand- 
ing, he was nauseated and fell in a faint. Upon waking, his 
fingers were stiff and he had pains in his legs. He got better 
in the reserve hospital and was sent back to the line. On the 
way he had a similar seizure, with nausea and fainting. On 
the way back to Berlin, he had a seizure in the railway sta- 
tion, and was carried to the Charite Clinic. At the clinic 
he stated that he could feel an attack come on ; that he first 
had Angst all over his body, and that it was hot inside of his 
head. Latterly he had been able to stop an attack by 
clenching his teeth, after which the attack would not proceed 
except that all became black before his eyes. 

He was observed for four weeks but no seizure appeared. 
He was somatically negative; his Wassermann reaction was 
negative. There was nothing hysterical about his make-up; 
he was somewhat surly and of low mental grade. He was 
unwilling to walk alone for fear of attacks. 

As to the heredity of this soldier nothing is known. He 
had been an illegitimate child ; he was a sleep-walker in child- 
hood ; he had sometimes spoken out loudly in sleep as a boy. 
At school he had been somewhat backward, fought readily 
with his mates, and often complained of dizziness and head- 
aches. He could not stand smoking or drinking well, getting 
drunk upon two glasses of beer. He had not held positions 
well. He became a pionier in 1914, working chiefly as a 
tailor. 

Early in his time as a soldier he had obtained an ulcer 
of the glans, which had been excised and burned. There 
had been no secondary symptoms. 

According to Bonhoeffer, this is an example of a not 
infrequent condition. Although the attack itself and the 
habitus of the patient did not look hysterical, the manner in 



70 EPILEPTOSES 

which the attacks repeated themselves speaks for psychogenic 
components. Just as genuine hysterical attacks may be 
looked on as reactions to unpleasant situations, so may these 
attacks. In fact, we are probably dealing with an hysterical 
fixation of the symptoms of emotional fright like those in the 
true hysterias following shell explosion. A great many of 
the phenomena of Shell-shock, to use the English phrase, are 
not in and of themselves of a psychogenic nature, but they 
are, according to Bonhoeffer, psychogenically liberated under 
the influence of unpleasant ideas. 

Re reactive epilepsies, Bonhoeffer considers that there is 
a group of reactive epilepsies in which the war process plays 
an important part. The prognosis of these cases ought to 
be relatively favorable. In point of fact, Case 57, although 
a feebleminded subject, seems to have had a relatively fav- 
orable prognosis: at all events, no new seizures appeared 
under prolonged medical observation. These reactive seiz- 
ures may occur in cases with a labile vasomotor system. 
They are, according to Bonhoeffer, aligned rather more 
with hysteria than with genuine epilepsy. Genuine epilepsy 
has not been developed in the war cases observed by Bon- 
hoeffer except where an endogenous factor was clearly in 
evidence; or else where there was the requisite antebellum 
soil for the development of an epilepsy. In short, genuine 
epilepsies developing in the war are all, according to Bon- 
hoeffer, predispositional. The antebellum soil was clearly 
in evidence in Case 57. Even before the war, according to 
Bonhoeffer, many German soldiers during the period of mili- 
tary service gave evidence of their epileptic soil by sundry 
suspicious phenomena. Among these were fainting spells 
during hard drilling and other exercises, spells of enuresis, 
abnormally deep sleep, and even phenomena of somnambu- 
lism. One of the Bonhoeffer epileptics had been released 
during his reservist practice as unfit for military service, 
and had only been put into the line at his own urgent request 
at the outbreak of the war. Three volunteers concealed 
their epileptic history. One man, who had had merely petit 
mal attacks before the war, regarded them as of little con- 
sequence, entered the service, and developed epilepsy. 



EPILEPTOSES 71 



Responsibility of a drunken epileptic. 






Case 58. (Juquelier, March, 191 7.) 

The question of responsibility arose in the case of a soldier 
who left his camp the morning of October 23, 191 6, and went 
to a neighboring place, where he drank, with four others, 
two quarts of wine. At about three o'clock in the afternoon, 
his captain met him on the street, lost, and looking drunk. 
He told him that he would send him to the trenches in the 
evening. The man lay down and went to sleep. At about 
six o'clock, it was found that he could not put on his equip- 
ment alone, and in fact threatened the other men with his 
bayonet, and then went to sleep. He woke up and explained 
that he had had one of his nervous crises. He remembered 
the matter of the bayonet but had forgotten everything else 
about the struggle. 

This soldier was 29 years old, the son of an alcoholic, and 
the ninth child of a mother who died shortly after her tenth 
pregnancy. He had had measles and bronchitis as a child, 
and in childhood had had bad dreams; at the age of ten he 
had swooning spells. He became a quarryman and a habit- 
ual drinker, subject to dyspepsia, nightmares, and nocturnal 
cramps. There had never been any crises, however, up to 
wartime. 

January, 1916, when a shell burst near him, the first sharply- 
defined epileptoid crisis came, and was followed by a number 
of others, either on leave or on service, March 8, June 2, and 
July 13. These attacks showed a sudden fall without warn- 
ing, loss of consciousness, convulsions, tongue biting, incon- 
tinence of urine, a period of more or less coordinate agitation 
at the time consciousness was reappearing, sometimes a 
fugue, and often amnesia for the whole. He had a scar on 
the left border of the tongue. 

Should this epilepsy be regarded as entailing irrespon- 
sibility? He left camp before the crisis, accordingly in a 
period when he was in full possession of consciousness and 
will, and he had gotten into an irregular situation by drunk- 



72 EPILEPTOSES 

enness before his epileptic crisis started in. His struggle 
with his comrades, however, appears to be a portion of a 
post-critical dazed state. The medicolegal decision, therefore, 
was that he was guilty of leaving his command but not of 
the other misdemeanor. Considering the general nature of 
epilepsy, the responsibility of this man for the whole adven- 
ture is rather slight. The Council, however, comdemned 
the man to five years of labor, without admitting that the 
crisis following so soon the actual misdemeanor should argue 
a diminution of responsibility. 

Re epilepsy in the army, L6pine notes the serious theo- 
retical and practical problems to which it gives rise. In 
the first place, epilepsy occurs in the army more frequently 
than in the same number of men in civilian life. Conse- 
quently, the diagnosis as to the really epileptic nature of the 
attacks observed is not too easy. Again, the situation affords 
much opportunity for simulation (see, for example, the case 
of sham fits (Case 78, Hurst), and the case of epileptoid at- 
tacks controllable by the will (Case 79 of Russell). Wounds 
may produce it, and even wounds which do not affect the 
brain; besides which, a variety of war conditions, short of 
trauma, may produce it. When the ordinary impulsiveness 
of the epileptic turns into automatism and to epileptic equiv- 
alents (Stats seconds) y much of medicolegal interest may 
happen. Case 58 was just short of a murderer. Cases of 
actual murder in epileptic equivalents have been known under 
military conditions. Fugues with amnesia for the phenomena 
(which look to the military man like intentional desertions) 
form another group of epileptic events; but aside from the 
manias and the fugues, there are still more dubious epilep- 
toid phenomena of a delusional and confusional nature, such 
that the proof of epilepsy comes only afterward, when frank 
convulsions supervene. Re fugues and desertion (the most 
frequent of military delinquencies according to Regis), we 
may think of the fugue reaction, according to Lepine, as a 
natural reaction on the part of both the true delinquent and 
the mentally sick subject. The loss of liberty, alcohol, 
fatigue, minor phenomena of commotio cerebri, may lead to 
states of mental depression that favor the fugue. It is an 



EPILEPTOSES 73 

affair of the greatest delicacy for the expert to build up 
again the exact plight of the soldier at the time of his deser- 
tion. Special inquiry must be made of the man's mates.^ 
Only in this way can the wheat be separated from the chaff 
and punishment allotted to those only who deserve it. 

According to Lepine, there are fewer guilty fugitives than 
there are innocent ones, or at least partially innocent ones. 
In the decision, one takes account of the duration, the course, 
and the peculiarities in the termination of the suspicious 
flight. According to the military code, there are cases like 
Case 58 in which the fugue itself was carried out in an un- 
conscious state, and yet in which the martial responsibility 
of the man was absolute. Drunkenness is no excuse for the 
fugue, even if the latter is automatically carried out. Of 
course, the paretic is not responsible for his fugue any more 
than the organic dement, the delirious uremic, or the chronic 
alcoholic, who is already severely demented. For a case of 
this sort, see Case 1 (Briand) 

In the differential diagnosis, we must also consider that 
fugues may be carried out in confused states as well as at 
times in various paranoid states, and even in melancholia. 



74 EPILEPTOSES 



A disciplinary case : Epilepsy. 



Case 59. (Pellacani, March, 191 7.) 

A Milanese workman, 28, was exposed to the sun on sen- 
try-go and had an attack of convulsions, on awaking from 
which he found himself in hospital. He always had attacks 
in reaction to emotion. One day, in a quarrel provoked by 
jealousy concerning a prostitute, he apparently lost his mind, 
whipped out a hunting- knife, and wounded a comrade. 
Thereafter he lay unconscious until the next day. The 
court-martial decided that he was not fully responsible. 

Eventually, he was sent from the front for having insulted 
and struck a superior officer. The report read also that he 
was a prey to delirium and had frothed at the mouth. In 
the interior he had convulsive attacks, with falling and loss 
of consciousness. He told of arguing with a sergeant about 
a bicycle, of seeing darkness before his eyes like a veil, and of 
subsequent amnesia. In hospital he had intense headaches 
at times, with spells of sullenness, hostility, and complaints 
concerning nurses and attendants and other patients. At 
other times, he was quiet and comfortable. One day he 
went into an excitement and wept, asking to be sent back to 
the army, striking the table with his fist and head. He then 
screamed, flew into a passion, and fell to the ground in semi- 
stupor, shaking his body and trying to kick and knock away 
those who intervened. He was placed in bed but remained 
agitated and unconscious, with anesthesia and frothing at the 
mouth. The abdominal and cremaster reflexes were absent 
in this attack, and the pupils were rigid and myotic. The 
pulse was rapid and the blood pressure high. Afterwards 
he was sleepy, stupid and weary, and showed fine rapid 
tremors of hands, tongue, and eyelids. The abdominal re- 
flexes now returned in excess, and a marked dermatographia 
developed. 

Upon investigation, it was found that the patient's father 
was also an epileptic and was alcoholic; that one paternal 
uncle had died in an asylum; another of apoplexy; that two 



EPILEPTOSES 75 

maternal uncles were chronic alcoholics (one in an institu- 
tion) ; that an alcoholic brother had been six times convicted 
of assault and battery; that a sister had howling, crying, and 
hair-pulling spells, throwing herself to the ground. The 
patient himself had had an early Bright's disease and had 
always been an undisciplined, excitable, and impulsive boy, 
sometimes kept out of school. His first conviction was at 
1 8, for assaulting a policeman, and he had been arrested 
four further times for assault and battery. He stated that 
his convulsive attacks with the veil before the eyes came on 
when he was irritated or had taken cold, or had drunk to 
excess, or had over-exerted himself. He said he suffered 
from intense headache, weariness, and sleepiness after an 
attack. He always bit his tongue at the same period. Irrita- 
tion and exertion sometimes caused attacks of dizziness and 
vertigo without unconsciousness. Alcoholism; ulcer in an 
inguinal gland. He had been confined in an asylum 40 days 
for epilepsy, attacks of which had become more frequent 
after he had heard of his father's death. 

Re violence and epilepsy, Lepine remarks that a pure 
epilepsy unclouded by alcoholism may occasionally give rise 
to acts of extreme violence, but these pure epileptic violences 
are infinitely rarer than the alcoholic ones. The Milanese 
was in point of fact alcoholic, and in his ancestry were a 
number of alcoholics as well as epileptics. According to 
Lepine, when subjects are "out for blood," they are almost 
always either, like this Milanese, hereditary alcoholics, or 
else strongly predisposed subjects, or even the offspring of 
the insane. 



76 EPILEPTOSES 

A disciplinary case : Epileptic attacks with amnesia. 



Case 60. (Pellacani, March, 1917.) 

A Veronese, 23, quarrelled with his comrades, and one day 
wounded one. Another time, when reproved by a superior, 
he struck him with a shoe; and at still another time, hurled 
himself upon his superior officer and bore him to the ground. 
Yet he seemed to have a perfect amnesia for all these violent 
acts. At other times, he had convulsive attacks with a 
mental state which seemed to combine anger and depression, 
after which he would fall to the ground, lose consciousness, 
go into clonic spasms, spit bloody saliva, and cause wounds 
and abrasions upon his body. Once, after such an attack, 
he passed into a brief excited spell. Finally he was so in- 
subordinate and violent to superior officers, that he was 
brought under hospital observation, having been excited and 
confused for a day. 

Next day he was lucid, oriented, and tranquil; entirely 
amnestic for what happened the day before, though his acts 
were sufficiently unusual. He had threatened his superior 
officer and been reproved and sent to prison to think it over. 
In prison he had suddenly thrown himself against another' 
innocent person and clutched him tightly about the neck. 
He threw another violently to the ground and then ran to 
help the previous victim! Bound fast, he had succeeded in 
freeing himself and thrown himself furiously against the prison 
door, whereupon he had fallen to the ground in an epileptic 
fit. He had tachycardia (120) and a generalized* hypalgesia. 
The vasomotor reactions were excessive. 

Upon investigation it proved that his mother had been 
subnormal and that the patient had been constitutionally 
excitable and unstable, given to attacks of anger and im- 
pulsiveness from youth up. In fact, he had been in prison 
several times for violence. He described himself in his rest- 
less spells as feeling a trembling all over his body as if his 
blood were boiling in his heart and his head, whereupon he 
would lose knowledge of what he was doing. He had been a 



EPILEPTOSES 77 

quarrelsome boy, pursuing his mates with knives and stones. 
Once, after arguing with a car conductor, he had broken the 
car windows, turned everything upside-down, and thrown the 
conductor into the street. 

Case 60 is clearly in the same group as Case 59. The 
Veronese falls into the same frame with the Milanese except 
that he appears not to have been alcoholic. The insub- 
ordinations of the Veronese were apparently carried out in 
a state of unconsciousness. The majority of insubordinates 
appear not to be epileptics. Some authors have called atten- 
tion to pathological politeness as an occasional symptom in 
epilepsy. Perhaps the majority of insubordinate cases are 
feebleminded or schizophrenic. 






78 EPILEPTOSES 

Desertion in epileptic fugue. 



Case 61. (Verger, February, 1916.) 

A blacksmith from the Rochefort Arsenal, 27 (nothing 
known as to grandparents; father, now in the fifties, for 30 
years in an asylum with frequent attacks of furor; mother, 
45, well and apparently well-balanced; brother with the 
colors, wounded and decorated with the military medal; a 
cousin-german, who has had a typical epilepsy — in the 
patient himself enuresis up to 13 or 14, later, less frequently; 
apparently no tongue-biting; no information as to infec- 
tious diseases; graduate from primary school, apprenticed 
to a blacksmith; an unskilful worker; never able to rise to 
the level of a frappeur), in 1909 had passed the board of 
review and been put in the sixth division of the line. Ante- 
bellum there was a history that one night at supper, he had 
slipped away from quarters and gone 30 kilometres, home. 
His astonished mother sent him back to the military post by 
railway. 

Upon the night of May 26-27, I 9 I 5> this soldier found 
himself in the position of a sentry, opposite the enemy. He 
told his comrade that he had to go away for a time, leaned 
his gun against a tree, disappeared, and did not return. It 
was then one o'clock in the morning. At six o'clock, he was 
found two kilometres away from the lines, in a village. He 
was in front of a barn where his company had been quartered 
before taking possession of the advanced posts. 

He was brought up before the military authorities; but 
upon stating that in civil life he had wandered off several 
times without knowing where he was going, he was submitted 
to neurological examination. There was available a letter 
from his family physician relative to his antebellum military 
service. It appeared that he had committed a number of 
breaches of discipline, and that he was regarded by the physi- 
cians as a desequilibre. He had lived with his mother a very 
quiet and good life; there was no history of sexual irregu- 
larity, and no history of illness except a slight catarrhal 
jaundice. He had frequently suffered from headaches; there 



EPILEPTOSES 79 

had been slight attacks of vertigo of very brief duration. He 
had never fallen in these fits. From his story it was elicited 
that he had had absences ; his comrades had noticed that he 
sometimes stopped stock-still with vague eyes, then shortly 
regained his wits and continued upon his task. Sometimes 
he would not work without being able to explain why he 
went away. He would go off for a period and, upon coming 
to, discover that he had not eaten his meals. There were 
never, however, any convulsive crises by day or night. He 
sometimes felt sick, and although there was no medical 
treatment, from time to time he took bromides upon his own 
authority, saying he had been ordered to do so by his father. 
Although habitually of a gentle demeanor, nevertheless he 
was subject to excessive anger upon slight occasion. 

During the mobilizing and first months of the war, both 
in quarters and at the front, however, his conduct had been 
that of a good soldier. Suddenly, about March or April, 
1 91 5, the nocturnal enuresis began to be frequent again, 
occurring twice or three times a week; but the patient hid 
this misfortune as far as possible from his comrades. The 
captain thought he looked tired and depressed sometimes. 
Upon the days following the nights with enuresis, there was 
intense headache and marked moral and physical depression. 
There was no proof of nocturnal convulsions, and it is very 
problematical whether there was tongue-biting. 

Another odd feature was that the patient, who had been 
sober in civil life, had become intoxicated several times after 
going into the army. Physically, he was of low stature, but 
otherwise well built. Neurologically, he was entirely nega- 
tive. There was no sign of venereal disease. There were a 
few stigmata of degeneration; for instance, there was very 
little hair upon the face, the ears were unequal in size, and 
the teeth were somewhat anomalously set. Mentally, he 
was below par; for instance, he could not add mentally two 
numbers of two digits. 

As to his desertion, the patient says he does not know 
what he did; that he learned of his act only from his com- 
rades in the morning; that he remembered having left his 
duty pour alter satisfaire un besoin. 



80 EPILEPTOSES 



A specialist in escapes (epileptic fugues) 



Case 62. (Logre, March, 191 7.) 

An epileptic fugue with recidivism is described by Logre. 
He described himself as a specialist in escapes. As a school- 
boy, he had practised escapes and run away without purpose, 
and without remembering fully what he had done. His 
father would bring him back to school. At first they had 
punished him and then would pardon him. These escapades 
in his work as a shoemaker caused him to lose various places, 
but he had been kept by one employer for a long time never- 
theless. From 11 years on, this patient had never ceased 
living either in foreign parts or in prison. 

The fugues on military service began to multiply. The 
military chiefs did not abide the escapades like the school- 
master or the employer. Every punishment he received had 
to do with some fugue. Three times he gave himself up to 
the military authorities. Three times after a few more days' 
service or a week in prison, he left the barracks or escaped. 
There had never been any appeal throughout this history to 
an alienist. On the declaration of war, he had returned to 
Belgium and was put into the army; whereupon in January, 
he carried out a fugue of a few hours which was rewarded 
with eight days in prison. There was a five-days fugue in 
July, whereupon he was taken before the council. 

Upon investigation, these fugues seemed to have the 
classical features of epileptic fugues. They were sudden, 
unconscious, blindly automatic, almost completely forgotten 
afterwards and of a stereotyped and recidivistic nature. 
Most of the fugues had been preceded by a slight excess in 
drinking. An investigation was made to see if there were 
any convulsive antecedents; none were found. This mental 
epilepsy, then, it was thought, must be an isolated symptom, 
free from every motor symptom. But his mother and one 
of his brothers had also shown a number of attacks of some 
sort of epilepsy. In all three cases there was impulsivity, 
unconsciousness, absurdity, recidivism, and refractoriness to 



EPILEPTOSES 8 1 

treatment. On these grounds the fugue was regarded as 
pathological and as epileptic probably. The patient him- 
self thought that these coups-de-tete and this mania for run- 
ning away without knowing where, made really a very ugly 
fault, particularly in a soldier. 

Re such specialists in escapes as Case 62, Lepine speaks 
of a type of military delinquent which he calls Ceux qui 
saute nt le mur. Some of the fugue subjects, as well as other 
types of imbalance can apparently be held by no possible 
kind or degree of discipline. They jump any guardhouse 
or any other form of imprisonment through what amounts 
to a wild instinct for liberty. In some cases, this instinct 
appears in a relatively pure form; that is, without any 
combined tendency to dipsomania and without any sexual 
factor. Some of them are, in fact, very good soldiers, espe- 
cially in shock troops. They, in fact, belong to what one 
might call the good element among delinquents. In the 
French Army some of them have been old legionaries and 
have even been, as in Case 62, previously condemned for 
desertion. They form a curious minority among the wall 
jumpers. Wall- jumping makes, so to say, the entire patho- 
logical phenomenon, and the recidivism is a part of the 
disease. 






82 EPILEPTOSES 

A disciplinary case : Epilepsy and other factors. 



Case 63. (Consiglio, 1917.) 

An Italian private in the artillery (father dead of general 
paresis) had been a victim of infantile convulsions and of 
convulsions with loss of consciousness up to 18 (convulsions 
with shouts and violence in the streets of Rome; had to be 
put in a straight- jacket at the municipal hospital). 

He developed more convulsions during antisyphilitic treat- 
ment in the military hospital. He was a very poor soldier, 
of the rough and violent sort, and after eight months of ser- 
vice had to be assigned to a special disciplinary company, 
with which he remained for fifteen months. Here also he 
was punished frequently, and was given a period of four 
months' imprisonment for refusal to obey the officers. Then 
for a period of several years he had no convulsions whatever. 

During the war he was given to alcoholism, and one day in 
June, 1916, he struck an officer and ran away to arm himself. 
He was at this time observed by psychiatrists and declared 
sane. He was regarded as an emotional and alcoholic epi- 
leptic but not as neurotic or psychopathic. He was again 
placed in a special disciplinary corps. 

Re the convulsions which this Italian developed during 
antisyphilitic treatment, it would be interesting to know 
whether intravenous injections were used. In case they were 
used, one might compare the case of this Italian with Bon- 
hoeffer's volunteer who developed epileptic convulsions after 
antityphoid inoculation. 

Re the insubordination and violence of this Italian, com- 
pare remarks of Lepine noted under Cases 59 and 60. Re 
the "other factors," compare remarks of Bonhoeffer noted 
under Case 57. 



EPILEPTOSES 8* 



An epileptic goes through Mons and two years fight- 
ing without symptoms. Then strange conduct with 
amnesia. 



Case 64. (Hurst, March, 1917.) 

A private, 26, epileptic from n to 18 (mother also epilep- 
tic) entered the army at 20, attempted to commit suicide in 
1912 (amnestic for this attempt), and went to France with 
the expeditionary force in August, 19 14. The retreat from 
Mons and further fighting caused no recurrence of the symp- 
toms. September, 191 6, he was in fact put in charge of 
eight men doing guard duty. At this time he was able to get 
to bed only every other night. The charge of the telephone 
worried him, as he had never before been made to assume 
responsibility. After two months of this, he was found one 
night arresting civilians without cause and driving them be- 
fore him with fixed bayonet. He was let off court-martial on 
the medical evidence, and at hospital remained confused and 
suspicious. November 16, he was seen by a medical officer 
in a typical attack of petit mal. Of all this, on reaching 
England December 19, he had no recollection, and was keen 
to return to duty. 

Re the remarkable delay in the return of epilepsy to this 
soldier of Mons, Bonhoeffer remarks that one of the epi- 
leptics observed by him at the Charite Clinic had passed 
through nine battles, and another through 18 battles before 
the first attack of epilepsy. Bonhoeffer regarded the stren- 
uous marching as a liberating factor of epilepsy in five cases, 
actual fighting in seven cases, shell explosions in two cases, 
and bullet wounds in three. 

Re the apparently psychogenic factor in Hurst's case 
(epilepsy coming on after assumption of too great responsi- 
bilities), compare remarks of Bonhoeffer under Case 57 con- 
cerning psychogenic factors. Sir George Savage has called 
attention to a form of functional epilepsy following shock or 
injury, in which recovery occurs after removal from the strain, 
but in which there is a relapse if the men go back to duty. 



84 EPILEPTOSES 

Therapeutic (antityphoid inoculation) epilepsy. 



Case 65. (Bonhoeffer, July, 1915.) 

A volunteer without psychopathic signs except a slight 
stuttering, and without psychopathic history of any sort, 
went into service at 17. After he had been a short time in 
the field, a shell fragment injured him in the upper part of the 
thigh. He lay up in hospital four weeks. He then spent 
four weeks in the reserve. 

He was then given antityphoid inoculation, and a half 
hour afterward had epileptic convulsions. These appeared 
four times more during the next fortnight, as a rule followed 
by a delirious excitement. No fever was reported. After 
the fourth attack, he was transferred to the Charite Clinic. 

At the clinic there were no attacks, and there was nothing 
epileptic to discern in the make-up of the patient. His 
nervous system was normal to examination. There was, 
however, one fact in the family history of note, namely, 
that an older brother of the patient, 20 years of age, suffered 
from convulsions. 

What is the relation of the antityphoid inoculation to the 
epilepsy? According to Bonhoeffer, we must not forget the 
family history even if we regard the inoculation as the lib- 
erating factor. Curiously enough, the shell injury did not 
itself serve apparently to bring out the epilepsy. Bonhoeffer 
has seen three other instances of epileptic attacks or epilep- 
toid phenomena following antityphoid inoculation. How- 
ever, in the hundreds of thousands of inoculations, it is not 
to be wondered at perhaps that there should be a number 
of instances of epileptic attacks. One was a man with 
severe epileptic taint ; in the others, there was a question of 
pathological intoxication. 

Re antityphoid inoculations, a French observer — Paris 
— remarks that these inoculations may occasionally start 
up the symptoms of general paresis. Compare in this con- 
nection also Case 63, in which a syphilitic developed convul- 
sions during antisyphilitic treatment. The psychogenic 
factor of intravenous injection itself, with its possible effect 






EPILEPTOSES 85 

upon glands of internal secretion, can hardly be distinguished 
from purely serological effects. Paris goes so far as to state 
that he regards it as imprudent to vaccinate a syphilitic 
subject. He thinks it might be better for a syphilitic sub- 
ject to contract typhoid or paratyphoid fever than to run 
the risk of developing paresis. If the soldier happened to 
be not only syphilitic but alcoholic, then the danger would 
be larger. Possibly, however, both Bonhoeffer's case of anti- 
typhoid inoculation epilepsy and the cases alluded to by 
Paris of antityphoid inoculation, are merely statistical 
accidents. 



86 EPILEPTOSES 



Shell-shock; (apparently slight) scalp wound: 
Jacksonian seizures. Operation, decompressing 
the edematous upper Rolandic region. Recovery. 



Case 66. (Leriche, September, 191 5.) 

A Moroccan of the Seventh Tirailleurs was thrown to the 
ground by the explosion very near him of a large calibre shell, 
lost consciousness, and woke up with a slight contusion of 
the right side of the head. The date of this injury is un- 
known. He was evacuated to the interior, but stopped 
May 25, 1915, at the evacuation hospital because his pulse 
in the train stood at 51. An hour later in the hospital he 
had a Jacksonian epileptic attack, followed by a left-sided 
flaccid, brachial monoplegia, and after a quarter of an hour a 
second crisis, and then a third, — a sort of epileptic status 
occupying an hour. The attack seemed to start in the left 
hand. After the crisis, hand and arm became flaccid and inert. 

Lumbar puncture in the crisis gave fluid under small 
tension in a few absolutely limpid drops. The wound was a 
superficial skin wound as big as a 25-centime piece, near the 
middle line, roughly corresponding with the upper Rolandic 
region. It was hardly a wound — a mild abrasion not pass- 
ing the epidermis; periosteum and bone intact. 

The patient was trephined and a thin layer of clot was found 
over the dura mater. The clot was removed and a crucial 
incision was made into the dura mater. The brain seemed a 
little edematous, hemorrhagic and bruised. It soon began to 
beat and was tamponed. 

May 26, complete brachial monoplegia without seizure. 

May 27, seizure at 2 in the afternoon, starting in left arm. 

The wound was going well and from this time forward 
no more seizures. May 28, a cast was made for the hand. 

June 4, lumbar puncture yielded a clear liquid under the 
pressure of 58. That evening an hour after the puncture, 
the brachial monoplegia disappeared. The arm was still a 
little weak June 5. June 8 the man was evacuated to the 
auxiliary hospital at Laversine. June 18, complete recovery. 



EPILEPTOSES 87 



Fall and blow to head: Hysterical convulsions. 
Cure by studied neglect. 



Case 67. (Clarke, July, 1916.) 

Clarke had seen in the war but one case of hysterical 
convulsions, though this particular patient had severe hystero- 
epileptic fits occurring in series. The man had never suffered 
from epilepsy and was 20 years of age. He received a slight 
wound and fell back into the trench a distance of six feet, 
striking but not contusing the back of his head. 

On admission to the hospital he was found drowsy and dull. 
Fits occurred a week later, following one another at brief 
intervals in series that lasted one or two hours. The arms 
would be raised and extended in clonic spasm; the patient 
would resist violently if held, and then turn to his right side 
with rigid extension of legs and back in opisthotonos. The 
eyeballs underwent irregular movements, and there was a 
well marked hippus. Though the tongue was protruded in 
these attacks, it was never bitten. It was doubtful whether 
there was a complete loss of consciousness. Between at- 
tacks, the patient was morose and sullen, and showed a vary- 
ing incoordination of the movements of the left leg, which 
was anesthetic to the knee. There was also a glove anes- 
thesia of the right forearm and hand. Fields of vision were 
contracted. 

The fits recurred with intervals of a day or two, for a 
fortnight. The patient was then strictly isolated in a small 
room with an observation window. His bed was made up 
on the floor. He then had very slight attacks, as a rule when 
the nurse came into the ward; no notice was taken of these 
attacks and in a fortnight they ceased. The paresis of the 
leg and the anesthesia also cleared up without treatment. 
He remained in the general ward three weeks longer, at first 
dull and listless, but later cheerful and active. Clarke 
suggests that this patient was below normal intelligence. 



88 EPILEPTOSES 

Shell injury with unconsciousness; delayed at- 
tacks of epilepsy : superposed hysterical hemihypes- 
thesia. Previous history consistent with the hy- 
pothesis that a genuine epilepsy had been developed. 



Case 68. (Bonhoeffer, July, 1915.) 

An excellent soldier, of good build, 29 years, a member of 
the Landwehr, passed unscathed through eleven battles in the 
1 9 14 campaign, but finally succumbed to fragments of shell 
which struck his chest and the lower part of his thigh. He 
fell down, nauseated, and lost consciousness. He is said to 
have struck about him with his arm and to have voided urine. 
There was a second attack three weeks later, in which he 
fell upon his face. 

In the Charite Clinic he had three attacks, two of them 
nocturnal, one in the daytime, followed by a long period of 
somnolence. He once cried out suddenly in the night as if 
warding off an attack. He complained of headaches, and was 
often irritated and out of humor. Somatically, there was a 
hemihypesthesia on the side of the injury. 

The history indicates that this patient up to his sixteenth 
year had been a victim of occasional enuresis, often cried out 
in his sleep or even rose from bed. Occasionally he suffered 
from such violent sudden headaches that he would have to 
sit down. He was easily irritated, and had once been ar- 
rested for assault. As a soldier, however, he had never been 
guilty of any breach of discipline. Mild headaches would 
follow drinking. These phenomena in the history pointed 
in the direction of epilepsy. According to Bonhoeffer, we 
cannot entirely exclude contusion of the brain from the shell 
injury. However, there were no cerebral symptoms, and 
the interval before the occurrence of the attacks rather in- 
dicates that we are dealing with a genuine epilepsy. As for 
the hemihypesthesia, this is a hysterical " superposition, 11 
which does not interfere, according to Bonhoeffer, with the 
genuineness of the epilepsy. 



EPILEPTOSES 89 



Shell-wound; musculocutaneous neuritis: Brown- 
Sequard's epilepsy. 



Case 69. (Mairet and Pieron, January, 1916.) 

An infantryman, 30, a gardener, was wounded in the right 
forearm by a shell fragment, which fractured the ulna, Sep- 
tember 7, 1914, at Revercourt. Despite much fragmentation 
of the bone and suppuration, the wound healed with two 
cicatrices, where the fragments had gone in and had come 
out. The scarring process was over in December. 

However, in the middle of January, 191 5, this man began to 
suffer from headaches and insomnia, with vertigo and buzzing 
in the head, " as if an airplane inside.' ' Sometimes arms 
and legs would stiffen, and the man would tremble, have to 
lie down, and even lose consciousness for a quarter of an hour, 
waking up tired, wandering, and with feelings in his head. 
These crises, at first occurring every week, later grew fre- 
quent. Finally there was a very complete attack, in which 
he fell out of bed, got up, made several turns about the room, 
and went back to bed ; and in the morning, was dull and dis- 
oriented. Accordingly, he was sent to the central military 
neuropsychiatric service of the general hospital at Mont- 
pellier, November 10. 

Besides the two extensive cicatrices, there were motor 
disorders. Pronation and supination were almost impossible, 
as well as extension of the hand and fingers and abduction of 
the thumb. There was a radial paralysis without R. D. 
Electrical excitability of the extensors was diminished on 
the right. The hand was weak. The right thumb was 
atrophic. There was a hypertrichosis as well as redness, heat 
and perspiration of the right hand. There was a hypesthesia 
for all forms of stimulation in the hand, especially in the 
radial region ; less in the ulnar region. This hypesthesia rose 
along the posterior surface of the forearm and covered all 
the territory of the ulnar nerve; but there was a correspond- 
ing hyperesthesia in the musculocutaneous distribution, as 
well as in the internal cutaneous distribution. Above the 



90 EPILEPTOSES 

scar"there was a region of complete anesthesia. The hyperes- 
thesia rose higher along the circumflex nerve and the posterior 
branches of the cervical nerves and included the great occipi- 
tal distribution, even involving the superficial cervical plexus, 
though not the territory of the trigemini. There was some 
hyperesthesia of areas governed by a few dorsal intercostal 
nerves. There were also spontaneous pains in these hyper- 
algesic regions. The musculocutaneous nerve could be felt to 
be thick and swollen, indicating a perineuritis. There were 
no neuropathic stigmata, but the knee-jerks were exaggerated 
a little more on the right side. 

The convulsions appeared two or three times a day, the 
pain would get worse along the arm, rise to the head, follow- 
ing the hyperesthetic zone, then invade the interior of the 
head, whereupon objects would appear to turn and the ears 
would buzz. The right leg, and especially the right arm, 
would begin to tremble. The man would have to support 
himself to avoid falling. He saw shadows moving, colored 
trees, occasionally persons. When the vertigo got stronger, 
he lost consciousness. The extremities of the right side 
stiffened and carried on jerky movements. These some- 
times extended to the left side. The seizure lasted from five 
to fifteen minutes, and sometimes occurred in the middle of 
the night. Fatigue followed but headache disappeared after 
an attack. 

The diagnosis of Brown-Sequard's epilepsy was made. If 
the musculocutaneous trunk was compressed, a crisis was 
produced with pain radiating to the head, obscuration of 
vision, numbness in the arm, and tremors. Electrical treat- 
ment was resorted to for analgesic effect. There was a 
certain improvement during May, so that the diurnal diz- 
ziness disappeared. May 19 he had a period of 24 hours 
without any vertigo. In June no further improvement 
occurred. 

An operation was performed June 23, 191 5. The two 
cicatrices were excised, and some fragments of cloth were 
removed. Three Jacksonian crises followed the operation, 
and there was another seizure next day. Frequent head- 
aches followed without crises. More seizures appeared in 



EPILEPTOSES 91 

the night during July, and their frequency increased. Pains 
persisted along the arm and in the back of the head; the 
musculocutaneous perineuritis was still intense. Prolonged 
baths for the arm were begun August 4, two baths of two 
hours each, at 40 deg. each day. Following August 10 
there was an improvement, which stopped as soon as the 
baths were omitted, with diminution of the vertigo and the 
hyperesthesia. This improvement continued ; the baths were 
made to last three hours. There were no attacks from 
August 21 to 26 whereupon they then returned for two days. 
The pains had much diminished in the arm but persisted 
in the occiput. A few night attacks occurred August 30 
and 31, September 5 and 6, as well as September 19 and 20, 
25 and 26, and 27. 

The occipital pain had now become less; the musculocu- 
taneous nerve was not so large. Only a few headaches 
followed during the months of October, November, and 
December. After November 3 the baths were stopped and 
the arm was kept wrapped in a warm compress. There was 
still a certain hyperesthesia, the knee-jerks had become less 
exaggerated. Massage and mechanotherapeutic exercises 
were begun. There were no more attacks after September 27. 

Re Brown-Sequard's epilepsy, Lepine remarks that besides 
the case of Mairet and Pieron, Hurst and Souques have pub- 
lished cases. Lepine himself has observed two cases: one 
followed a nerve wound in the foot; another, a penetrating 
wound of the chest. As a rule, such Brown-Sequard epi- 
lepsies appear a number of months after trauma ; as a result 
of irritation in the scar. Lepine' s subjects were taken for 
simulators because they had not received any cranial wound. 
The prognosis should be guarded, though the outcome in 
Case 69 appears to have been favorable. 






92 EPILEPTOSES 



Epileptic episode at 24 years following bullet-wound 
of hand, in a soldier who had had convulsions in 
childhood (sister epileptic) . Reactive epilepsy ? Epi- 
lepsia tarda ? 



Case 70. (Bonhoeffer, July, 191 5.) 

A man in the reserve, 24, bore the stresses of the war very 
well in the campaign in East Prussia until he was shot in the 
hand at Deutsch-Eylau. He had always been well aside 
from rheumatism, and was discharged with a good record 
from his military service. 

Sent to the reserve hospital for his hand injury, he had, 
two or three times in the night, convulsions with loss of 
consciousness and dilated pupils; after which there was a 
thirty-six hour period of depression with refusal of food. 
Thereafter this soldier had amnesia for both the seizures 
and the subsequent depression. He was observed six weeks 
longer in the Charite Clinic but had no more attacks, and 
indeed nothing more of note either mentally or somatically. 

The history showed that there had been convulsions in the 
third and fourth years of the patient's life. There had been, 
however, nothing epileptoid in the later childhood or develop- 
mental years of the patient. However, a sister of the patient 
had suffered since childhood from convulsions. It remains 
a question whether this episode is to be regarded as reactive 
epilepsy — reactive, namely, to experiences in the war — or 
whether we are dealing with a true epilepsia tarda. 

Re this episode following bullet wound, the compiler has 
placed it after Mairet and Pieron's case of Brown-Sequard 
epilepsy, but apparently Bonhoeffer regards his case as prob- 
ably a reactive one. Unlike the case of Mairet and Pieron, 
Bonhoeffer's case had an epileptic soil (convulsions in child- 
hood and epileptic sister). Re the so-called reactive epi- 
lepsies, see remarks by Bonhoeffer under Case 57. 



EPILEPTOSES 93 



Epilepsia tarda in a lance-corporal without heredi- 
tary taint or previous history save dizzy spells and 
excitability. 



Case 71. (Bonhoeffer, July, 1915.) 

A reserve lance-corporal, 24 years — a soldier from 191 1 
to 19 1 3 without disciplinary record, and in his second year 
becoming lance-corporal — was in the campaigns in Belgium, 
East Prussia, and Poland, making long marches and going 
through several battles. In the middle of October, 1914, 
he fell from a horse and suffered a contusion of the thorax, 
after which blood appeared in the sputum. In November he 
was brought to the reserve hospital in Berlin, and there had 
convulsive seizures. Before transfer to the Charite Clinic, a 
seizure occurred, and he was brought into the clinic in a 
characteristic dazed state. Thereafter he was clear but often 
out of humor and irritated. Three weeks later came a brief 
attack, probably epileptic in nature, with restless half- 
delirious sleep following. 

There was nothing in childhood or in the family history 
to indicate epilepsy. However, the patient himself stated 
that from 191 3 onward, after his period of military service, 
he had from time to time felt attacks of dizziness after 
exertion, and that he had become more easily excitable than 
before. 

The attacks in the lance-corporal are probably not to be 
attributed to the thoracic contusion, according to Bonhoeffer, 
because of the long period that elapsed after the thoracic 
injury, and their development nocturnally without special 
occasion. According to Bonhoeffer, we are probably here 
dealing with a late epilepsy. 

Re late epilepsy, see also under Case 57. Bonhoeffer makes 
a considerable point of the lateness in attacks of epilepsy in 
some of the military cases, pointing out their beginning at 
the ages of 22 to 27 in the period of peace practice under- 
gone by soldiers. The theory is that cases of severe and 
long-standing epilepsy are known to the authorities, so that 



94 EPILEPTOSES 

they would not ordinarily be in military service except under 
conditions of concealment or in case of error. The present 
case (71) appears to be the nearest that Bonhoeffer has 
found to a case of epilepsy without heredity and without 
acquired soil. All that can be regarded as evidence of soil 
is the dizzy spells and excitability. 

Re thoracic contusion, compare remarks of Lepine under 
Case 69, on Brown-Sequard epilepsy following thoracic 
wound. 



EPILEPTOSES 95 

Convulsions by autosuggestion. 



Case 72. (Hurst, November, 1916.) 

A private, 27, is described as a typical martial misfit — 
in private life a music hall falsetto singer, and afterward a 
valet. He joined the army in 191 5 and proceeded to France, 
and worked in a canteen. A week later, men broke in and 
threw a mallet at him, whereupon he immediately had a fit, 
and was dazed, dumb, and unable to walk for two days. 
Thereafter occasional further fits occurred, with nervous- 
ness and insomnia. He was sent home in September, 191 6. 
Discharged to duty, he again in December returned to France, 
had six fits in the first week — three in hospital, two on the 
boat, and between two and four for four days after admission. 
The diagnosis of genuine epilepsy was made in France by a 
medical officer who had seen one of the convulsions. How- 
ever, he had never passed urine or bitten his tongue, had no 
family history, and had never had fits before going to France. 

He was hypnotized and given the suggestion that he would 
have a fit. In the convulsion which followed the plantar re- 
flexes remained flexor, but otherwise the convulsion was 
quite like the genuine epilepsy. He was told that he would 
not have any more convulsions, nor did he have any more 
except on Feb. 16, 191 7, when some talk was made to him 
about returning to duty. Bromides used in France did not 
help the epilepsy at all. This patient deyeloped a gait and 
speech defect copied from two patients in the wards. These 
symptoms, due to autosuggestion, disappeared on persuasion. 

Re autosuggestion, Bernheim has returned to the fray 
(191 7) in a book on automatism and suggestion, dealing only 
in small part with war problems. The most general formula 
for suggestion appears to be that it is an idea accepted. A 
suggestion offered but not accepted is in effect not a sugges- 
tion at all. Any accepted idea, says Bernheim, is from the 
psychological point of view as well as from the medical point 
of view, a suggestion. A suggestion may be direct or in- 
direct, reasonable or unreasonable, brought about by 



96 EPILEPTOSES 

(a) mere verbal assertion, 

(b) hypnotic state, 

(c) persuasive explanation, rational or emotional, 

(d) emotion (that is, emotion not the effect of any form of 
suggestion offered by the physician, but emotion brought 
about by some event affecting the sentiments of the subject). 



EPILEPTOSES 97 

Epilepsy of emotional origin. 



c 



Case 73. (Westphal and Hubner, April, 1915.) 

A lieutenant without neuropathic tendencies (except that 
his mother was in a hospital for the insane) was under shell 
fire for some time. Finally, a shell burst near him, whereupon 
headaches and transient spells of confusion followed. Shortly 
upon the news of the death of his Major, he had a spell of 
violent excitement and confusion, dancing about on the 
ground and breaking things up. He passed into a stuporous 
condition with a suggestion of catatonia. There were a few 
isolated delusions to the effect that he was poisoned. After 
sleeping a long time, he suddenly cleared up. There was an 
extensive amnesia covering a period of weeks. He had for- 
gotten the Major's death and everything thereafter. He 
complained of headache, difficulty of thinking, and forgetful- 
ness. An agoraphobia developed, as well as great sensitivity 
to sounds, and a feeling as if the bed and surrounding barracks 
were moving. There were a few illusions of a visual nature. 
He had complete insight into his condition. Conduct was 
normal. There was general hyperesthesia and ageusia. 

According to Westphal, this case of deep disorder of con- 
sciousness of some duration in a healthy person is probably 
one of a dazed state following the so-called " affect epilepsy/' 

Is Case 73 Shell-shock? Note that, in Case 73, the shell 
explosion at first occasioned mere headaches and confusional 
spells. The true occasion of the convulsions appears to have 
been the news of the death of a superior officer. It is, of 
course, possible that the transient spells of confusion were 
actually epileptic equivalents. Lepine remarks that Pierret 
and others, observing such spells of confusion often accom- 
panied by agitation, have inquired whether manic depressive 
psychosis is not a kind of epilepsy. This question remains 
unresolved. These phenomena of epilepsia larvata (see also 
Case 81 of Juquelier and Quellien) are to be sharply distin- 
guished from attacks of confusion occurring in pronounced 
epileptics. These latter attacks often follow a crisis and 
suggest exhaustion; sometimes they last several days. 



98 EPILEPTOSES 



Fatigue; fear; hysterical convulsions. Visual aura 
(approaching fire wheel) built up after the third crisis 
(scotoma after look at sun). 



Case 74. (Laignel-Lavastine and Fay, July, 191 7.) 

A sapper, 23, with his company under heavy bombardment, 
October, 191 6, was overcome by weariness and fear (he had 
always been of a timorous disposition). The order for the 
rear came, but the convoy was hardly en route when the 
sapper felt a griping in the pit of the stomach and the blood 
going to his head ; whereupon he lost consciousness and went 
into convulsions. 

This incident seems to have made a powerful impression 
upon the sapper. A fortnight later, while working in the 
trenches, he had more epigastric sensations with vague dis- 
comfort. He thought about the earlier crisis and about his 
wounded comrades, and again fell down and had more con- 
vulsions lasting a quarter of an hour. The tongue may have 
been slightly bitten in this seizure. In the genesis of this 
second seizure we may consider that the feeling of discomfort 
and the epigastric sensations served to recall the first seizure, 
so that the second one may be regarded as due to auto- 
suggestion — that is, as hysterical. 

A little later, on a hot day in the trench, while working, 
the sapper turned to a comrade and saw a great black spot 
on his face. He turned toward another and saw another 
great black spot on this face also. He was frightened, felt 
strange sensations, fell, and had a third convulsive crisis. 
The black spots that he saw were due to a scotoma, the 
result of a transient glance at the sun. 

After this scotomatous episode, his crises always had a 
visual aura. He would feel rather uncomfortable, leave the 
supper table, feel a gastric sensation, warmth in the face, and 
oppression. He would go out in the cold for the air, look 
about for something, appear frightened, fix his gaze upon a 
certain point, and cease to reply to questions. His head 
would jerk back suddenly, and he would utter strangled cries 



EPILEPTOSES 99 

of fear. He was now evidently prey to a terrifying hallu- 
cination. In ten minutes, everything had gone again, leaving 
him trembling with emotion. He would then relate how, 
after the epigastric sensation had begun, he tried to see if he 
could make out something abnormal; whereupon a little 
fiery wheel would appear and roll up nearer and nearer, so as to 
almost touch his eyelids. He could see his comrades to the 
right and to the left of the wheel ; he could hear questions but 
could not answer. Just as the fire wheel was about to blast 
him, consciousness was lost and the fits came on. 






100 EPILEPTOSES 



War strain ; anxiety ; confusion ; fugue. Demotion 
and detail to the interior. 



Case 75. (Barat, November, 1914.) 

A lieutenant, 25, an officer in a regiment on active duty 
near the front, was called before a special board charged with 
desertion in the face of the enemy. He had been assigned to 
a certain position but not only had not complied with the 
order, but had wandered off to the British sector and been 
arrested there as a spy. 

The prisoner was well developed, without stigmata ; hered- 
ity, negative. His career in the army had been courageous 
and he had been advanced several ranks and was about to 
be given a medal for bravery. He said that he had been 
under a severe strain for several days. 

One evening he had been given the order to attack. The 
artillery opened fire. He found that the Germans had erected 
barbed wire defences. The loss of men was terrific. His order 
was to shoot all who held back. A poor territorial crouched 
down and would not go forward — supplicating the prisoner 
not to shoot him. The prisoner spared him. 

The next night the order to attack the German trenches 
was again given. This time he was overcome with anxiety 
and discouragement. The last he remembers was the order 
to attack. Next day he felt sick and his mind was foggy. 
He remembered leaving his regiment and wandering round 
for several days until he fell into the hands of the British 
and was arrested, 't hen he understood what he had done. 

The prisoner asked to be allowed to return to the front. 
The testimony of one of the lieutenant's men verified his 
statements. On the day before he left the front he had been 
anxious, had cried often, and would speak to no one. On 
the day he left the trenches without permission, he was 
nervous and disoriented. 

There was no doubt that simulation could be ruled out; 
the differential diagnosis lay between a " confused state of 
emotional origin " and an " epileptic dazed state." 



EPILEPTOSES 1 01 

For epilepsy there was a history of attacks with falling to 
the ground and loss of consciousness, without involuntary 
micturition or biting of tongue, during the time when he was ! 
a sergeant. Moreover, irritability and unwarranted sus- 
piciousness had been present at these periods. However, 
there were no other epileptic symptoms; these two attacks 
were isolated and of quite long duration, leaving no head- 
ache or malaise after them. Also there was no basis for the 
diagnosis " epileptic dazed state," since there was no abrupt 
commencement; the loss of consciousness was never com- 
plete (the subject was able to converse with persons while the 
attacks were on); and some remembrance was present of 
incidents during the attacks. 

For Barat, the important points are that the attacks were 
preceded by long periods of anxiety and the disturbances 
resulted more from moral than physiological causes. 

The importance of the psychological factors lead the author 
and his colleagues to the diagnosis " Mental confusion of 
emotional origin. " 

The board decided to return him to the interior and give 
him a barracks position at the reduced rank of drill sergeant. 



102 EPILEPTOSES 



A solitary epileptic episode in an artillery officer 
(slight concussion of the brain two years before) 
following extraordinary campaign stress (38 artillery 
battles in two months). 



Case 76. (Bonhoeffer, July, 191 5.) 

A first lieutenant of artillery, 35, was able to count 38 
artillery clashes in which he had taken part in two months 
of very strenuous, almost daily fighting. Then appeared 
headaches, anxiety, dizzy feelings, insomnia. Finally one 
day suddenly, after eating, the lieutenant sustained a loss of 
consciousness with convulsions, which sent him to his home 
reserve hospital. The officer had felt nothing before his 
convulsions came on. The medical report, however, yields 
no doubt of the epileptic character of the attack. 

When he was examined, there was a slight psychopathic 
depression with a feeling of insufficiency, anxiety, insomnia, 
restless dreams, over-sensitiveness, and a pessimistic out- 
look on the future. There were no epileptic traits whatever. 
There was nothing alcoholic, luetic, or arteriosclerotic about 
the officer. There was nothing in the childhood or youth of 
the patient, though there had been a fall two years before, 
with phenomena of concussion without sequelae. In fact, 
this fall with concussion had led to no medical examination. 

As to the relation of the concussion two years before to the 
epileptic attack, Bonhoeffer is inclined to interpret the case 
as one of genuine " reactive " epilepsy on the basis of con- 
tinuous overstrenuous work for a period of weeks. He re- 
gards the previous concussion as soil for this epilepsy. 

Re amount of stress occasionally required to bring out 
epilepsy, compare Hurst's Cases 64 and 80. It may be 
recalled that Bonhoeffer is decidedly of the belief that ex- 
haustion has not brought about any actual psychoses, calling 
attention to the remarkable absence of psychoses among the 
Serbians after their exhausting campaigns. A general re- 
view of war experience indicates, according to Bonhoeffer, 
the marked power of resistance of the healthy brain. 



EPILEPTOSES 103 



Nocturnal narcoleptic seizures accompanied by 
spells of somnolence in the day, both to be regarded 
as due to the " brain fag " of trench life. 



Case 77. (Friedmann, July, 191 5.) 

A tradesman, 23, had been in the German infantry since 
the beginning of the war. Never sick, he had been, in a 
general way, nervous; and a brother had had, at the age of 30 
years, some sort of severe brain disease, in which he became 
blind, dying a year later. 

The man was for a long time in the trenches and proved 
himself a courageous and stalwart soldier. He went to 
hospital after a slight bullet wound of the leg, with a benign 
paralysis of the peroneus. 

In the hospital he began to show a somewhat pronounced 
emotional depression, with a nervous tachycardia. 

Friedmann reports the case on account of certain peculiar 
seizures which, upon the man's own story, had begun five 
weeks before, in the field, although he had told no one about 
them. He had never felt anything like them before. At 
first, they came three to five times almost every night. He 
would suddenly wake and find himself unable to move, to 
speak, or even to think. These seizures, however, were not 
accompanied by any feeling of anxiety or any respiratory 
distress. Consciousness remained clear, and after 10 or 15 
seconds, he could begin to think normally again. It was 
clearly a question of psychopathic absences of a mild nar- 
coleptic type, occurring, however, only at night. 

Daytimes, also, throughout the whole period in which 
the nocturnal absences occurred, there were seizures of an- 
other description. During the many hours in which he had 
to sit in the trench, about twice a day for half an hour long, 
he would plunge suddenly into a sort of irresistible lethargy. 
Without any external occasion whatever, there would be a 
feeling of great fatigue. In the spell he could not move or 
think, would lean his head upon his hand. He was unable 
to overcome the feeling of weariness and became convinced 



104 EPILEPTOSES 

that he was ill, and that the fatigue could not be natural. 
However, he did his work like the rest. Friedmann inter- 
prets these spells as a kind of imperfect sleep. 

The patient was physically healthy and stalwart, mentally 
not excitable, and tolerably tranquil in the midst of shell 
fire. He would never have been reported sick had it not 
been for his wound. Aside from the tachycardia, of which 
he himself complained little, nothing wrong was found in the 
hospital. There was, to be sure, a feeling of discomfort 
without any hysterical tinge, and sleep was restless. Aside 
from the peroneus palsy, the injury made a good recovery. 
The nocturnal attacks persisted ; bromides and even luminal 
failed of effect. There was, however, no longer any som- 
nolence by day. In fact, for the five weeks of observation, 
there was no change in his condition. 

Friedmann states that mild emotional alterations are not 
infrequent in the trenches with minds disposed thereto, 
although emotional shock, especially in shell fire, is the most 
frequent cause. However, these particular seizures are quite 
unusual. The stresses of field service lead to a sometimes 
complete paralysis of mental power, interfering transiently 
with service. There is no evidence of sudden circulatory 
disturbances such as would bring about dizziness, pallor, 
nausea, or fainting spells. According to Friedmann, the 
regulative brain functions, especially those that maintain 
consciousness, become weak on account of a condition which 
he terms Gehirnmildigkeit, or, as we should say in English, 
brain fag. The situation forbids due completion of sleep. 
Thus, the explanation of the daytime attacks follows rather 
obvious lines of brain fag. The accidental awakening it is, 
which at night produces the absences ; the wakenings are due 
to the general restlessness of the patient. The general weak- 
ening of cerebral function produces the disorder at the mo- 
ment of wakening, since the regulative factors of conscious- 
ness are already out of order. The condition in the absence 
rather closely resembles the state of consciousness just before 
going to sleep, and also perhaps the state of consciousness 
during the process of awakening. It is as if the process of 
waking were somehow delayed a few moments. Friedmann 



EPILEPTOSES 105 

is interested to show the relation of such absences to the so- 
called gehduften kleinen Anfalle, originally described by him 
in 1906 as occurring in children, and distinguished from epi-^ 
leptic attacks. These attacks, after lasting for years, finally 
disappeared completely. The same sort of thing in adults 
was symptomatic of some other disease, such as neurasthenia, 
and was not a true entity. In children these attacks failed 
to be attended with any mental injury, nor were there any 
pronounced epileptic phenomena. Bromides had no effect 
upon them, and they already showed a somewhat striking 
and peculiar appearance, involving interruptions ten seconds 
long of capacity to think, speak, or move, without disturb- 
ance of consciousness or automatic movements. Sometimes 
the attacks occurred from six to 100 times in the day, without 
in any respect interfering with the general condition of the 
child. The occurrence of such series of mild seizures is noth- 
ing but a syndrome. To be sure, some cases turn out to 
be cases of genuine epilepsy with an eventual degenerative 
process. Some forms belong in the spasmophilia group, and 
some among the hysterias. However, according to Fried- 
mann, there is a narcoleptic petit mal that is an entity by itself, 
proceeding after a period of years to complete recovery with- 
out complications. It is this form which may be regarded 
as a peculiar kind of brain fag. The case of the soldier may 
be supposed to be one which will prove to have this benign 
outcome. 



106 EPILEPTOSES 

Sham fits. 



Case 78. (Hurst, March, 1917.) 

An unwilling conscript developed numerous fits on board 
ship coming from Jersey, three days after enlisting. Fifty 
more developed during two days in hospital. He was sent 
to Netley. 

On the hypothesis of hysteria or malingering, he was hypno- 
tized. A fit was suggested to him, but did not come off. 
The Sister was informed in the patient's hearing that the 
man was clearly shamming, as in all genuine cases a fit would 
occur after this treatment. A fit with marked opisthotonos 
immediately occurred. This fit immediately stopped when 
he was ordered to stop it and to wake up. 

The man after waking promised to have no more fits. 



Epileptoid attacks, controllable by will. 



Case 79. (Russel, August, 1917.) 

A man was received in No. 3, General Hospital: Diagnosis, 
epilepsy. He was shortly sent to the convalescent camp 
and then returned, having had two attacks. Russel watched 
for another attack, felt it was not genuine and "put the 
situation up to " the soldier whose story was as follows: He 
had been at the front without leave for twelve months since 
the German retreat. Leave was due him. A sister's letter 
said his brother was severely wounded and his mother was 
praying for his return. When he thought these things over 
an attack came. He could, however, control the attacks. 
Russel told him, if he would play the game, he would be sent 
to the base with a recommendation for leave. In ten days 
the man was remarkably changed and had no further attacks. 



EPILEPTOSES 107 

Hereditary epileptic taint brought out by two years 
service with eventual shell-shock and burial thrice 
in one day. 



Case 80. (Hurst, March, 191 7.) 

A private, 24, in the army from 16, never epileptic (sisters 
epileptic), was wounded four times in the war from Septem- 
ber, 1 9 14. Shell fire did not worry the man, but he gradually 
became depressed after his father and five brothers had died 
in active service. He was blown up and buried three times 
in one day in July, 19 16. He was unconscious for two hours 
after the second blowing up, but carried on for two hours 
more until blown up for the third time. 

After this, he became nervous and shaky, and began to 
sleep badly, and a month later had a typical attack of major 
epilepsy. Fits occurred with increasing frequency. As 
many as 19 occurred in a single day. Rest and bromides 
caused the fits to cease, and there had been none for six 
weeks at the time of his discharge. 

Re the extraordinary delay in the bringing out of this 
epileptic's taint, refer back to Case 76 of Bonhoeffer, with 
its discussion, and to another case of Hurst (64). 

Re Shell-shock and its relations to epilepsy, see below, dis- 
cussion under Cases 82-84 of Ballard, who has erected a 
theory of Shell-shock as in some sense epileptic. 



108 EPILEPTOSES 

Shell-shock : Epilepsia larvata. 



Case 81. (Juquelier and Quellien, May, 191 7.) 

A soldier, 29 (father alcoholic, died in hospital for the in- 
sane), a decorative painter without plumbic history, non- 
alcoholic, non-syphilitic, was wounded once, September, 1914, 
but returned to the front in 191 5. 

May, 191 5, a shell burst near him. He lost conscious- 
ness, regained it a few days later at Brest, and was so far 
recovered that he could go on leave in seven days. While 
on leave, he had short attacks of delirium, followed by a 
total amnesia; there was, however, no crisis, fall, or convul- 
sion. After the first attack, he had for 24 hours malaise and 
headache, but got well and went back to his depot. Shortly 
afterward more attacks of this sort recurred, and he went to 
hospital and thence to the neurological centre at Tours. 
Whence, August 9, 191 5, he got a two-months* leave for 
"mental disorder post-confusional, second Stat, probably 
hysterical (commotio cerebri), and organic hemiparesis." 

November, 191 5, after returning to the depot, there were 
more spells and he went again to hospital. Invalided 
December, 191 5, he passed a year at home, but the spells con- 
tinued. Although the epileptic nature of these attacks was 
maintained by Francais at Evreux, he was placed in the 
auxiliaries, December, 19 16, but had to go to hospital almost 
at once, and, February 28, 191 7, entered the neurological 
centre of the 9th Region for the second time. Here, when 
called to be examined two days after admission, he was 
observed in an attack. He suddenly rose from the bench, 
made a few steps, seemed to be listening and anxious, as if 
he ought to be on guard. He looked up, seemed to be look- 
ing for something whose noise was approaching, lowered his 
head, made a slight jerking movement, and said, "Poum!" 
as if to express the noise of an explosion. He took a few 
more steps, the same movements were repeated, and the 
same "Poum! " was uttered. This lasted for about a quar- 
ter of an hour, during which the patient was unaware of his 
surroundings. He could be guided all about the hall without 



EPILEPTOSES 109 

resistance, but did not respond to orders, commands, noises, 
or contact. In short, the patient was in the midst of a 
hallucinatory dream at his post in the trenches, undergoing 
a bombardment. He was placed in a chair; remained 
motionless for a few seconds, woke up, and answered ques- 
tions. "Where am I? Oh, yes; I must have been sick 
because my head feels bad." In answer to the question. 
"What did you see; what was there?", he said, "I don't 
remember anything. I never remember. I don't know." 
The patient was dull and weak after the spell. 

These spells varied in number but occurred once a week. 
The patient was able to tell of certain attacks that had 
occurred while he was out of doors at home. 

Now and then, there was another theme in the halluci- 
natory delirium, namely, a pencil drawing of a woman's 
picture, of no great artistic worth but carefully done, at 
which the patient was much astonished on awaking. 

It seems as if auto- and hetero-suggestion can be elimi- 
nated from the genesis of these attacks. Neither hysterical 
nor epileptic crises have preceded or ever alternated with 
these seizures. Nevertheless, on the organic side, the patient 
had a general increase of tendon reflexes on the left side, most 
marked in the knee-jerk, and fell to the left in voltaic ver- 
tigo. There was a left hemiparesis, apparently of organic 
origin, which had been determined as far back as July, 1915. 

There was no true dementia. Past memories were but 
slowly recalled, and inattention interfered with the fixation 
of recent memory. He complained of troubles in his sleep 
and dreamed of war experiences somewhat analogous to those 
in his attack of amnestic delirium. After the seizure, there 
was a marked hebetude and mental inactivity, torpor, and a 
severe headache. The case was presented to a special com- 
mission as one of epilepsia larvata in a person hereditarily 
predisposed who had never before presented epileptic signs, 
suffering from a disease characterized by frequent short 
attacks of hallucinatory and delirious automatism, following 
shell explosion which had at the same time produced a slight 
left-sided hemiparesis and mental inhibition. 



1 10 EPILEPTOSES 



To 


illustrate an 


epileptic theory of Shell-shock; 


three cases: 






i. 


Fugue; minor symptoms: later, 


epilepsy. 


2. 


Epileptic confusion eight months after ex- 




plosion. 






3- 


Mine explosion : stammering 


replaced by 




mutism ; 


mutism replaced by 


epilepsy. 



Case 82. (Ballard, 191 7.) 

Atmospheric concussion from shell explosion, October, 
1 91 5, was followed by unconsciousness in a soldier described 
by Ballard. 

Blindness for a month followed recovery of consciousness. 
"Neurasthenia" (anxiety neurosis) after return of sight. 
Apparently nearly complete recovery after latent period of 
a few weeks. Return of blindness in one eye in December. 
Five days automatic wandering (the man was found in a 
west country town five days after leaving home to rejoin his 
depot and seen by a medical officer who reported that he was 
dazed and amnestic for that period) ; admission to second 
Eastern General Hospital, December 15. 

On admission he proved to be suffering from minor hysteri- 
cal symptoms such as an inability to open his eyes and to 
see clearly when the lids were raised. The symptoms rapidly 
cleared up under suggestive conversation and did not return 
except for amnesia and slight emotional depression. He re- 
mained well until December 25. On that day he began for 
the first time to have definite epileptic fits and nocturnal 
epileptic delirium. In January he was discharged as an 
epileptic. There was no epileptic temperament or feeble- 
mindedness. Finally, there had never been any personal or 
family neuropathic or psychopathic history. 

Case 83. (Ballard, 191 7.) 

A soldier was blown up, April, 191 5, and had a spell of 
unconsciousness. Later, pains in the head, slight amnesia 
and a condition of asthenia developed. 



EPILEPTOSES III 

He was eventually admitted to the second Eastern General 
Hospital at Brighton, January, 191 6. At the time of admis- 
sion he was semiconscious, stuporous, confused, disoriented, 
anxious in a dull sort of way, talking about his expectation of 
"a sailor with a card." Speech was intelligible, though frag- 
mentary and infrequent. The man obeyed commands but 
gave no replies to questions. The mental processes were 
slow and impaired. 

According to Ballard, we have here a case of epileptic con- 
fusion, eight months after the initial concussion. This par- 
ticular attack ceased three days later, leaving amnesia for the 
attack and a certain amount of mental retardation. The 
man was not epileptic in temperament and his personal and 
family history proved negative- 
Case 84. (Ballard, 19 17.) 

A soldier was buried in a mine explosion, October, 191 5, 
and for several days thereafter was unconscious or semi- 
conscious. He emerged deaf and subject to stammering and 
a condition termed " neurasthenic." The stammering was 
soon replaced by mutism, which lasted several weeks. The 
mutism was then supplanted by epileptic fits. 

He was observed by Ballard in a dreamlike, disoriented 
and inaccessible state, in which he was anesthetic to pin 
pricks, lay awestruck, dumbly following with his finger hal- 
lucinatory airplanes. Flexibilitas cerea was also shown at 
this time. 

Next day he emerged from the dreamlike state with men- 
tal processes somewhat slowed, disorientation for time, am- 
nesia for the attack, memory disturbance and a return of 
the stammer. On the next day following, all these symp- 
toms had disappeared except amnesia for the attack. An- 
other spell of epileptic fits occurred later. It seems that the 
man had had a convulsion thirteen years before and occa- 
sional convulsions since. In fact, he, seven years before, 
had had what was called "a stroke " and residuals of a slight 
hemiplegia were still present. (There is no statement in the 
case report relative to syphilis.) 



112 EPILEPTOSES 



Emotion ; shell fire : Epileptic equivalents. 



Case 85. (Mott, January, 191 6.) 

A man, 19, suffered from shock due to emotional stress and 
shell fire. He had terrifying dreams. After a short time, 
he developed paroxysmal attacks of maniacal excitement. 
Just before the first attack he had been helping in the kit- 
chen, lay down on his bed, went to sleep, woke, startled, 
flushed, and sweating, and made for the door as if terrified. 
He remained in this state as if suffering from hallucinations 
of sight and hearing, and without ability to recognize his 
wife, the doctors, or the Sisters. When two strangers in 
uniform came in to observe him, the adjutant became vio- 
lent, as if the uniforms had started terror anew. The attacks 
lasted from a few hours to a few days, coming on suddenly, 
without apparent cause. One day he tried to get over the 
wall of the playground. He came back and buried his head 
in his hands. Major Mott spoke to him, whereupon he got 
up, looking terrified, made for the door, and four orderlies 
were required for his restraint. At Napsbury Hospital, to 
which he was sent, he made a complete recovery. 

Mott suggests that we are dealing with a psychic equiv- 
alent of epilepsy. 

Re epileptic equivalents, compare notes from Lepine under 
58 and 59. 



IV. PHARMACOPSYCHOSES ^ 

(THE ALCOHOL, DRUG, AND POISON GROUP) 



Pathological intoxication. 



Case 86. (Boucherot, 19 15-6.) 

A Territorial infantryman, aged 37, was in the habit of 
drinking a good deal without getting drunk, and at the front 
drank a good deal of bad brandy. He had just taken a con- 
siderable quantity when his regiment got the order to charge. 
The charge was hardly over when the man became greatly 
excited and hallucinated. He thought he was surrounded by 
Germans and tried to transfix his comrades with the bayonet. 
Howling and struggling he was carried to the rear. 

He was soon brought to the asylum at Fleury after howl- 
ing all night and seeing the Boches and animals fighting 
among themselves. His hands and tongue were tremulous 
and there were cramps in the calves of his legs. On the 6th 
he expressed astonishment to find himself in hospital and 
was found to have but slight memory of what had happened. 
He remembered, however, that he had tried to kill his com- 
rades. With the deprivation of alcohol he became rapidly 
normal and was sent back to the dep6t in a few days. 

Re alcoholism under army conditions, Lepine remarks that 
alcohol has played in this war a r61e analogous to that of 
malaria in the epidemiology of some countries. Many of 
the victims are, to start with, unbalanced subjects and 
detragues who are hereditary alcoholics. Alcoholism, accord- 
ing to Lepine, dominates the pathology of the interior and 
has a marked bearing upon conditions at the front. In 
fact, alcoholism would have been disastrous in France had 
not measures been taken against it ; measures still insufficient 
(191 7). More than one-third of 6000 cases studied by Lepine 
during three years have shown alcohol as a sole or, at all 
events, principal cause of the difficulty. It would be within 

"3 



1 14 PHARMACOPSYCHOSES 

reason to state, according to Lepine, that if we throw in 
cases in which alcoholism was a partial factor, more than 
half, or even more than two-thirds, of the mental cases had 
been strongly influenced by alcohol. Lepine thinks there 
may be effects like those of anaphylaxis. Certainly, the 
startling and sudden effects in so-called pathological intoxi- 
cation, as in Case 86, suggest the critical and vehement 
effects seen in the sensitized anaphylactic subject. 



PHARMACOPSYCHOSES 



115 



PHASES OF WAR PSYCHIATRY IN FRANCE 



I. Antebellum phase of Psychiatric Neglect: Groundless fear that 
recruiting would be disorganized by psychiatric sifting processes. 

II. Phase of Alcoholism of Mobilization: Hospitals unprepared. 

III. Phase of the Marne: Alcoholism restrained jDy law; psychoses few; 

psychiatrists optimistic. 

IV. Phase of Trench Warfare: Overemotionality; and of High Ex- 

plosives (January, 191 5); now psychiatric services were syste- 
matically established along evacuation lines. 

V. Phase of Systematic War Psychiatry: Filterwise system of 
management (a) near trenches, (b) in main body of army, (c) on 
evacuation lines, (d) special hospitals. 

Chiefly from data of Chavigny, 191 5. 



Chart 4 



1 1 6 PHARMACOPSYCHOSES 



Pathological intoxication: criminal prosecution 
stopped. 



Case 87. (Loewy,i 191 5.) 

An orderly, in private life a teacher, one day about noon- 
time, when going on duty, called the commanding officer to 
account because he (the orderly) had had to wait. He said 
he had been ordered to come at two o'clock and it was al- 
ready long thereafter! He was severely reprimanded but 
addressed a number of the officers present with questions 
having no relation to military service. In fact, he seemed 
to have forgotten entirely that he was on military service. 

This was the more remarkable as the teacher-orderly had 
many times distinguished himself upon dangerous patrol 
expeditions and in critical situations, winning the confidence 
of his superiors and the likelihood of promotion to corporal. 
He had been a discreet, earnest, and clever soldier. 

Loewy observed him during this affair and noticed that 
he did not by language or movement suggest intoxication or 
hilarity but merely a certain excitement. He was entirely 
oriented for time, place and person, and his outward be- 
havior was correct enough except for his military rank. 

Sent to his quarters near by, he gave the impression to his 
immediate superior officer of deep drunkenness. He mur- 
mured something and soon fell into a deep sleep. After 
waking, he had an almost complete amnesia, knowing only 
that something disagreeable had transpired. He remem- 
bered that he had been offered several little glasses of cognac 
brandy by a comrade, and that he had drained them off 
quickly before going on duty. He said that he had never 
drunk cognac before, and in fact had drunk nothing for a 
long time. 

The diagnosis of pathological intoxication was made, and 
the soldier was thereby cleared of his dangerous situation; 
a criminal prosecution was not instituted. He thereafter 
behaved with entire sobriety and modesty, and he achieved 
his corporalcy and later became file leader. 



PHARMACOPSYCHOSES 1 1 7 



Desertion in alcoholism may deserve the term 
" pathological." Case of fugue. 



Case 88. (Logre, July, 1916.) 

A " deserter" said: "I went because I drank a glass. I 
just went, comme ca, without any motive." He was some- 
what feebleminded and, in explaining the impulsivity of his 
act, he added: "I went like a broken-down beast. I walked 
straight ahead, without knowing where I was going and if I 
had been going to be killed, it would have been all the same 
to me." He could not that afternoon remember very well; 
but next morning, after having slept, he regained full con- 
sciousness. He said that he then found himself in a field 
near a cemetery. He had carried his gun and equipment 
with him, but had lost them somewhere, and from a military 
point of view, his desertion was complicated by loss of effects. 
On coming to, he said to himself, "Where am I? How 
foolish after fifteen months in the line! Probably I have 
deserted again." In fact, he had a month before left his 
post under exactly the same conditions in the midst of a 
period of alcoholic excitement. 

This alcoholic fugue is typical : drunkenness, impulsive and 
subconscious ambulatory automatism, with partial amnesia, 
disorientation, with mislaying of objects, followed by sleep 
and immediate return to normality. 

Re fugue, see discussion under Cases 58 and 59. The 
French military code cannot excuse victims of fugue even 
though executed in a quite unconscious state, if the fugue 
is due to alcohol. There was a certain procursive sugges- 
tion in the fugue of Case 88, who went "like a broken-down 
beast," straight ahead, without knowing where he was going. 



1 1 8 PHARMACOPS YCHOSES 



Alcoholism: Amnesia experimentally reproduced. 



Case 89. (Kastan, January, 1916.) 

February 15, 191 5, a German soldier drank beer in the 
canteen and at roll-call appeared tipsy. He then went to 
bed, but rose an hour later to go to town. A quarter of an 
hour later, he went to a clerics house and asked for paper, 
on the ground that the next day he was going to march to 
Warsaw. The clerk gave him no paper, which he then tried 
to get by force. A policeman arrested him and he said, 
"You just wait, lame dog!" Upon examination he denied 
that he had ever been guilty of any crime but had been in 
institutions on account of delirium. In point of fact, this 
man had grown up in very bad surroundings, amongst quar- 
rels and disputes of his parents, who kept a disorderly house. 
At 19 he had been convicted of incest. He finally admitted 
having been convicted for rape. It was found that he had 
once run out into the front trenches ; had been removed by an 
advance guard to a stable, and then wondered why he was 
not in school. He described a number of attacks of delirium 
although he had not drunk more than moderately. 

He was given an experimental dose of 50 c.c. of alcohol, 
and in ten minutes became excited, tried to get out of bed, 
attacked other patients without reason, and was able to 
speak neither spontaneously nor in response to questions. 
In a period of two hours he became clear and asked what 
the trouble was. He knew only that he had taken alcohol. 

Re the experimental excitement produced in Kastan's case 
by the exhibition of alcohol, it is of note that Berard has been 
much impressed by the agitation that surgical cases of alco- 
holism undergo when anesthetized. It may be that the an- 
esthetics act similarly to the experimental alcoholism of 
Kastan's case. According to Berard, these phenomena of 
the anesthetized wounded (who are men recently evacuated 
from the front and other hospital cases) are of larval alcohol- 
ism brought out by the anesthesia. Berard wonders whether 
rum issues at the front are at all responsible therefor. 



PHARMACOPSYCHOSES 1 1 9 



Desertion, drunk. Contributory factors. 



Case go, (Kastan, January, 191 6.) 

Gottlieb S. left the barracks, January 25, 1915, met friends 
and drank with them, remaining all night in the railway 
restaurant and waiting room. He was promptly arrested. 

According to the patient, he had always drunk a good deal 
and had once fallen from his horse in the campaign, and be- 
come unconscious. After this fall, he said he had been able 
to stand less alcohol than before. 

There is doubt as to the syphilis of Gottlieb. He said he 
had been infected once, but his further statement that he 
had six relapses is, of course, questionable. As to the hypoth- 
esis of feeblemindedness, it appears that in childhood he 
had learned badly and had been a stammerer. He had been a 
herdsman, and after that a laborer. He finally became a 
travelling man for a specialty photographer. 

He had previously been convicted of an embezzlement, 
brawling, and breach of the peace. 

As to his military crime, he said he had been celebrating 
the emperor's birthday the last three days, being urged on by 
acquaintances and drinking whiskey. He was, in fact, on a 
spree and did not eat properly. He had met a student in 
the railway station and had forgotten all about his military 
service. He remembered having spoken with the waiter, 
remembered telling the student that he was going to commit 
suicide, and the student had drunk seltzer with him. Jan- 
uary 29, he for some reason drank no more, and then it 
occurred to him that he ought to go back to duty. He 
remembered that he was easily led astray. He had once 
thought of becoming a tanner but had been dissuaded from 
the trade because of its bad smell. 

The analysis of this case must consider, first, syphilis. 
Supposing, however, that this hypothesis is not sub- 
stantiated by laboratory findings, the hypothesis of 
feeblemindedness might well be raised. It seems pos- 
sible, if not probable, that this patient was in the 
subnormal group, lying between normality and feeble- 



1 20 PHARMACOPSYCHOSES 

mindedness proper. The value of mental tests would 
here be extreme. There seems to be no evident epi- 
lepsy, and the majority of the phenomena can perhaps 
best be explained by alcoholism. Possibly the case is 
one of so-called pathological intoxication. The pa- 
tient's own story that, although he had been always 
subject to drink, he had been less tolerant of alcohol 
since a fall from his horse, seems to be entirely consist- 
ent with the post-traumatic history of numerous cases, 
so that it would hardly be wise to consider that alcohol 
accounts for the whole story. We must raise then in 
succession the hypothesis of syphilis, feeblemindedness, 
alcoholism, and coarse brain disease, bearing in mind 
also early stammering. As to the utilization of such a 
man, it would appear that a supervision of him with 
absolute countermanding of alcohol in view of the de- 
crease in tolerance of alcohol since the fall from his 
horse might perhaps preserve this man for some form 
of military service. 

Re German and French war alcoholism, Soukhanoff re- 
marks that the conditions in these countries were in strong 
contrast to those in Russia. In Russia there was a great 
decrease in the number of cases of acute alcoholic psychosis; 
particularly at the time of mobilization, there were few cases 
of alcoholic psychosis. He says that during the Russo- 
Japanese war, alcoholic psychoses constituted a third of all 
the mental cases observed. This figure corresponds with 
that quoted above from Lepine (see under Case 86). Souk- 
hanoff, writing in 191 5, had not observed personally a single 
case of alcoholic psychosis. Incidentally, the number of 
cases of psychosis in the Russian army had remained in 
general small. 



PHARMACOPSYCHOSES 121 



Desertion by mild alcoholic dement. 



Case 91. (Kastan, January, 191 6.) 

Emil S. made a number of statements when he came for 
examination. He had once had a treatment by injections. 
Both his mother and his grandmother had been insane. He 
said that his brother was an officer in the navy, but this 
statement was found to be false. 

According to his story, he had lost touch with his troop at 
the end of September, 19 14, and had lived in several lodgings 

in T up to October 19, when he was arrested. He said 

that he did not know that a man who had lost touch with his 
troop had to report. 

A week after his arrest, S. entered a shop and asked for 
coffee, saying that he had a furlough of 24 hours and wanted 
cake for his comrades. He said he was the owner of an 
estate and would send a roebuck for the cakes. The shop- 
man gave him cakes to the value of one mark. Bystanders 

said that he had been lodging in T for about two weeks. 

It seems that he had told his landlady that a city official 
had quartered him upon her and that he was on furlough. 
He went away in the morning and came back in the evening. 
He had written to a bank of which he had once been a repre- 
sentative, asking for money. One night he had lodged with 
another landlady, being given a meal, and he had there 

stated that he was in the City of T on duty and that his 

horse was in the barracks. He offered a thousand marks 
for his board and lodging. 

At another lodging he had given himself out as a courier. 
In fact, the letter to the above-mentioned bank had been 
signed "Otto S., Land-owner, at present, courier." 

"If I do not revoke this in person or by writing on 
January 1, 191 5, I beg you to pay to Mr. and Mrs. M. 

of T , one thousand marks and deduct it from my 

balance. 

" This is to be considered as my last will. As witness : 
present: Joseph B." 

The letter was addressed "To the direction of Commercial- 
Counsellor P ." There was no stamp on the letter. 



122 PHARMACOPSYCHOSES 

A second letter reads: 

" Honored Sir, Commercial Counsellor: 

I beg you to send by return mail to the address given 
below iooo marks, and deduct this amount from my 
account. I have been in Russia. Well, things are 
moving now. Thank God, we have reached the point 
we have. Write me please more in detail about my 
property and estate and give me your very valuable 
advice. 

With best regards to your esteemed wife, I remain 
Sincerely and respectfully yours, 

Otto S., at present courier, 

otherwise, land-owner." 

As for this Commercial- Counsellor P., P.'s son stated that 
his father had been dead for three years and a half. 

S. gave himself out in T as a land-owner, falsifying 

his name, asking for beer to the amount of a mark a day, 
borrowing from his landlady ten marks, paying nothing, but 
remaining on friendly terms with the landlady and her women 
lodgers, making a contract with a superintendent ostensibly 
for his estate, and borrowing money from him. 

Observed in the clinic, he said he was a bank represen- 
tative and had been very nervous since being divorced in 
191 1. The divorce was due to his wife's adultery. Some- 
times he would not know really what he was doing, once even 
tried to shoot himself, and again once threw a burning lamp 
into his wife's face without knowing it. 

He had gone to the City of T without furlough in 

October because others used to, too. Only five days later 
had he noticed that his troop was no longer there; and upon 
inquiring about the troop he could find nothing as to its 
whereabouts. 

He had been a heavy drinker and was always somewhat 
intoxicated, which, according to the patient, made him forget 
everything. He had drunk 20 glasses of beer and liquor 
daily. He wrote to P. because he knew his father. 

As for the frauds, he said he knew nothing about them. 
He did not know even the baker from whom he had gotten 
the cakes. In fact, he had been drunk the whole day long. 



PHARMACOPS YCHOSES 1 23 

He said that he had learned badly in school and had not 
passed any examinations. In active service he had already 
been convicted of drunkenness once. Referring to his treat- 
ment by injections, he said he would rather be dead. He 
had only sought diversion in looking over estates. Both his 
ability to reckon and his memory had suffered greatly. He 
and another patient eloped from the clinic one day but were 
captured a few hours later. 

Remarks: Details are lacking as to the physical and 
laboratory side of this case. On the whole, there ap- 
peared to be no convincing features of paresis or cere- 
brospinal syphilis. The phenomena are very possibly 
in part alcoholic. There appeared to be no sensory 
disorders, and in particular no hallucinations. The in- 
tellectual disorder is chiefly amnestic. There is little 
or no evidence of emotional abnormality. The curious 
conduct seems hardly to indicate a primary disorder of 
will. The main feature psychologically appears to be 
amnesia coupled with an inability to reckon. To be 
sure, the letters are written externally in sufficiently 
good form; the amnesia does not appear to extend to 
details. It is a question of whether the disorientation 
which one suspects is not merely amnestic. On the 
whole, however, it would appear that there must have 
been at various times disorder of consciousness, as in- 
deed is indicated by the patient's own account of his 
ignorance of the cake-roebuck episode. 

Dismissing the hypothesis of a syphilitic dementia, 
we might cling to that of alcoholic dementia more or 
less punctuated by acute alcoholism. Yet it is also 
possible that the patient was actually somewhat feeble- 
minded; this would be consistent with his own state- 
ment. The question might arise whether this soldier 
could have been excluded by careful psychiatric ex- 
amination before entering service. It would seem that 
a knowledge of the insanity of the mother and grand- 
mother, and an inspection of school records, if available, 
— to say nothing of the episodes which may or may 
not have been accurately related, between himself and 
his afterwards divorced wife — would have sufficed to 
throw doubt upon the military effectiveness of this 
man. We know also that he had already been con- 
victed of drunkenness on military service before the 
episodes mentioned. 



1 24 PHARMACOPSYCHOSES 



Desertion by alcoholic. Contributory factors. 



Case 92. (Kastan, January, 191 6.) 

Carl B. was a soldier about whom the captain thought that 
his intellectual power had been weakened by drink. An 
inquiry after arrest showed that he had been odd also at 
home. He had once been sued for perjury, but the suit had 
been stopped for lack of evidence. He had been several 
times convicted of drunkenness. It appears that on March 
30, 1 91 5, after mounting guard, he said nothing and went 
home, remaining at home until the next day and then re- 
turned to the guardhouse in the street-car. He declared, 
this time, that the non-commissioned officer had given him 
permission to leave, although this statement was not correct. 

Again, on April 6, B. was about to leave the quarters, 
but the surgeon, finding him drunk, kept him back. He 
did not go home that night, and the next day when he was 
wanted at the hearing, he could be found only in the after- 
noon. He replied confusedly and somewhat irrelevantly 
to the questions asked. On arrival at the clinic he was in 
tears and much depressed. Given 50 grams of alcohol, he 
became somewhat livelier. Upon examination, his percep- 
tions were found diminished; he felt, he stated, a cracking 
and crackling in his neck. In his cell he had felt as if spar- 
rows were roosting in his face; he had heard voices and seen 
pictures, and had not known what he was doing. He as- 
serted his innocence, blaming his imprisonment for all his 
troubles. He had been in the habit of drinking three 
liqueurs and two glasses of beer a day. He had been draw- 
ing a pension since a fall from a scaffold. 

A sister had suffered from continual headaches. The 
patient himself had three sickly children and ten of his 
children were dead; there were also two premature births. 

The analysis of this case would clearly show the 
benefit of considering, first, the hypothesis of syphilis. 
Not only is the history of his children suggestive, but 
the impairment of mind noted by the captain as due to 
alcohol may very possibly be syphilitic in origin. Ex- 



PHARMACOPSYCHOSES 12$ 

amples in division he could not solve, and it is a ques- 
tion whether his leaving guardmount is not in part 
related to disorientation for time. There appears to 
be no evidence of feeblemindedness and none of epi- 
lepsy (though a sister suffered from continual head- 
aches). Alcohol may account possibly for the entire 
picture and is particularly consistent with the false 
voices and figures, the sparrows in the face, and the 
sensations in neck and the tickling in the ears. It is 
possible, also, that intolerance to alcohol had set in 
since the fall from the scaffolding for which a pension 
was being received. It does not appear necessary to 
consider any further of the groups of mental disease. 
Syphilis, alcohol, and a post-traumatic brain condition, 
all may play a part. Alcohol is able probably by itself 
to produce a number of these symptoms, and these al- 
coholic symptoms would be probably the more readily 
produced in virtue of the post-traumatic intolerance 
that we may assume. 



126 PHARMACOPSYCHOSES 

A disciplinary case : Alcoholism, 



Case 93. (Kastan, January, 1916.) 

A German soldier, brought up for examination for dis- 
obedience and insubordination with intoxication, was found 
already to have been convicted 33 times of a variety of 
crimes. Once he had drunk a bottle of shoemaker's polish, 
evidently with suicidal intent. 

In the canteen he had assaulted superior officers and tried 
to strike a sergeant. He said he had been attacked by the ser- 
geant and pushed into a cell, whereupon he had lost his mind. 

He came from a family of drunkards, and had been him- 
self very alcoholic formerly. On the day in question, how- 
ever, he had drunk very little. According to his account, 
he had fits of this sort if any one injured him. He was 
amnestic and had forgotten his previous convictions. Any- 
thing he might have done, he said, had happened a long 
time ago, in his youth. For example, concerning a theft, he 
said that it was merely that he had fallen into some Christ- 
mas trees and stuck fast there, and no one wanted to be 
paid. Tremors of hands, feet, head. Analgesia of thorax. 

Re alcoholism and disciplinary cases, we find alcoholism 
bulking large in Lepine's account of military delinquency. 
Fugue subjects are not infrequently alcoholic. Minor dis- 
obedience is also often alcoholic. Acts of violence are char- 
acteristically alcoholic, or executed by subjects with heredi- 
tary alcoholic taint. (Such acts were in France especially 
common before the anti-absinthe law in 19 15.) Alcoholic 
episodes and impulses often culminate in arson. No doubt, 
espionage employs alcoholism for a portion of its technique, 
though delusional mystics and subnormal hypersuggestibles 
are more often the purveyors of information to the enemy. 
The theft list, also, shows its share of alcoholics. Alcoholics 
are less common amongst those who, contrary to rules, 
assume shoulder-straps or other decorations. Here the sub- 
normals and victims of imbalance, as well as the drug cases, 
are more likely to figure if the matter is psychiatric at all. 



PHARMACOPSYCHOSES 1 27 

Remarks upon an atrocity. 



Case 94. (Kastan, January, 1916.) 

April 15, 1 91 5, a German soldier went with three comrades 
to a farm, to select a sheep for slaughter; they were obliged 
to go to three farms. The man carried a revolver and cart- 
ridges in his pocket. He threatened the farmer that he met 
with this revolver, and desired to rape the farmer's daughter. 
He was very drunk, and said to the non-commissioned officer 
who was called in at the time, " You have served only a year 
longer than I have." He staggered, struck violently with his 
hand at the sergeant, and gave insolent replies. 

He had already choked the peasant's daughter, scratched 
her face, and bitten her fingers, hand and arm. She could 
not run away as she was lame. The soldier held the revolver 
to her face and shot it off several times, offered sex assault, 
scratched her feet with his spurs, and tried to twist her neck. 
The non-commissioned officer threatened to shoot him, and 
he then became still. He said to the first-lieutenant before 
whom he was taken, that he would do anything but allow 
himself to be beaten, and at this moment moved his arms 
about in the air, and bloody foam came from his mouth. 
The first-lieutenant previously had always thought him to 
be normal except for a strange flicker and unrest of the eyes. 
There was a history that he had already once attacked a 
servant girl. The man had amnesia for the affair, only 
remembering how the non-commissioned officer had come on 
a white horse. He remembered nothing about the peasant 
and the girl. He said that he had been given to earache on 
the right side in winter. There was a history of his having 
fallen from a tree in childhood, becoming unconscious. He 
had been a sufficiently good scholar up to the second class 
in school. He had been an excellent soldier. 



128 PH ARM ACOPS YCHOSES 



Alcoholism: Atrocity. 



Case 95. (Kastan, January, 1916.) 

September 15, 19 14, a German soldier was missed. He 
had said that he wanted to get to the enemy quickly, and that 
he was going to march alone against the Russians. A shot 
was fired that night by this soldier, on the ground that he had 
been insulted by a civilian, although no civilian was present. 

September 21, a farmer in a wagon reached a farm, where 
he found the soldier aiming at a woman. He fired, wounded 
the woman severely, and jumped on the farmer's wagon and 
rode "off with him. It seems that the soldier had come to 
the farm at noontime and accused the woman of treachery, 
ordering her to come with her husband to a certain farmhouse, 
where she should be placed against the wall and be shot. The 
soldier had shot her and wounded her husband also. Ac- 
cording to the woman, the idea was to take revenge because 
she had denounced certain persons as spies. 

He was arrested during the night, and told how he had left 
his troop because he could not get at the enemy. He had 
been informed that there were spies who ought to be shot; 
there had been talk in a certain inn about it. He did not 
know he had wounded the husband, and he only wanted to 
give that dangerous woman a piece of his mind. 

After wounding the woman, he had given himself no 
further thought about her, but had gone to partake of the 
holy sacrament at the pastor's. He then had drunk another 
glass of beer and gone to bed. He was, in fact, still drunk 
at the time of arrest. He had not been aware that he would 
be punished for the crime of going alone against the Russians. 

Some days later, he wrote that he did not intend to kill the 
woman, that he had been drunk at the time and was always 
a bad man when drunk; that he had other times when he 
absented himself from home for days when drunk. He had 
had, he said, a number of attacks of delirium, in which he 
had seen animals. At one time, he had fallen on his head. 
On the day in question, he had drunk if litres of liquor. He 
was remorseful for his deed. 



PHARMACOPSYCHOSES I29 

A disciplinary case : Alcoholism ; amnesia. 



Case 96. (Kastan, January, 1916.) 

A German soldier, New Year's Eve, 1915, got away from 
his company, drank whiskey, and came back drunk. He 
bothered his comrades so that the non-commissioned officer 
had to call for help; whereupon the soldier said, "A man who 
comes on late and hasn't been in much, hasn't much to say. 
If it is a non-commissioned officer, I shall hit him in the 
snout." The officer kept talking to him kindly but he cried 
"Halt's Maul, you crooked . . . ! " He staggered up to the 
lieutenant without saluting, but at a slight push fell prone 
into the straw. 

It transpired that the man had not been intoxicated 
enough to lose all control of himself. He did not remember 
anything about what he had done; he had drunk a half- 
bottle of rum during the evening. There was a demonstrable 
lack of memory. He did not know the German provinces, 
and thought that Bismarck had once been war minister. 
There was a tremor, hypalgesia of the left leg and analgesia 
of the left arm and left shoulder. 

It was found that he came from a strongly tainted family, 
with two insane sisters and three insane cousins. He had 
been a good soldier during his service, but had accused his 
father of alcoholism baselessly. He had always been difficult 
to manage when drunk and had been convicted nine times: 
five for dangerous assault and battery. He drank up to 1 J 
litres of whiskey a day if he got time, and also took ether. 
For some ten years he had been amnestic for what he did 
while drunk; nor, according to his wife, had he been able 
recently to stand so much alcohol. He said that he had had 
a fall from a wagon in 191 1 or '12, after which he had been 
unconscious. 



1 30 PHARMACOPSYCHOSES 



Antebellum, run over by an automobile; intoler- 
ance of alcohol; episodes of amnesia after moder- 
ate alcohol. 



Case 97. (Kastan, January, 1916.) 

A German soldier was advanced in rank February 26, 
1 91 5, and in honor thereof drank six or seven glasses of beer. 
On his way home, he met a captain and failed to salute him. 
When called to account, he said he could not see, and made 
remarks about regrettable behavior. He refused to go along 
with the officer. Afterwards he remembered that he had 
been stopped by an officer but had forgotten subsequent 
happenings. 

March 24, he was riding in an electric car with a lieutenant. 
He said to the lieutenant who had unbuckled his sabre, "It 
is a piece of insolence and improper to unbuckle the sabre.' 1 
He repeated the phrase on questioning. He was then asked 
to give his name, and replied, "I know my name but what is 
your name, Mr. Lieutenant? " He looked drunk at the time 
but afterwards remembered nothing. 

Physically he was tremulous and showed blepharospasm. 
His face grew red on bending over. 

This man had been run over by an automobile in 1910, 
after which he had become excitable, slow-thinking and 
forgetful. The spinous processes were painful on pressure, 
as was also the hip joint. The history showed that he had 
been convicted six times of various crimes, such as disturbing 
the peace, embezzlement, and the like. Since this accident 
he had not been able to work effectively. He had gone into 
the army in a spirit of enthusiasm. 



PHARMACOPSYCHOSES 131 



Adventure with a stranger in Paris. 



Case 98. (Briand and Haury, 1916.) 

A soldier had seven days' leave in Paris, beginning Decem- 
ber 27, 191 5, and the first day drank a good deal of wine with 
another man on leave. They met, in some place that the 
patient had forgotten, a well-dressed man whom they did not 
know, and all three fell to drinking. The stranger told them 
he knew a trick to prolong the leave to 3 or 4 weeks. "All I 
have got to do is to prick you, and it will cost only 100 sous." 
The operation was done at the cafe after payment in advance. 
The operation was a puncture with a needle between the 
middle and ring fingers of the left hand. Next day there was 
a phlegmon of the dorsal surface of the hand, and he was put 
into hospital saying that he had gotten a barbed wire prick 
in the trenches. The surgeon who opened the phlegmon was 
surprised at its gummy appearance, gangrenous odor, and 
greenish tint. In point of fact, petrol had been injected. 



Morphinism: Tetanus. 



Case 99. (Briand, 1914.) 

Mdm. L. was a morphinist. After the outbreak of the 
war, she went to a general hospital to recover from mor- 
phinism, but was too excited to be kept there. Accordingly, 
she had to be sent to Sainte-Anne, but upon arrival she 
developed distinct signs of tetanus. 

It seems that Mdm. L. was the widow of a Colonial who 
had given her the first injections ten years before, for dysen- 
tery. She tried several times to stop. Daily dose 1.5 grams. 

She was in a cachectic state, and according to her mother, 
took no care of her syringe, trailing it about everywhere. 
Her thighs, arms, and anterior aspect of the body were covered 
with scars. There were small phlegmons in places. Did she 
inoculate herself with bacillus tetani from an infected needle? 
In any case, she died of tetanus. 



132 PHARMACOPSYCHOSES 

Medicolegal question concerning a morphinist. 



Case ioo. (Briand, 1914.) 

A man worked in Paris on the 'Change, where there are a 
number of syringe victims. He had been brought up in Paris 
but was not a Frenchman. Enthused by his friends and the 
prey of deep emotion, he enlisted. He was of an introspective 
nature and himself wondered whether the morphine did not 
have something to do with his enlisting. He said, "I had 
been unnerved for a number of days by reading the papers, 
and after a number of heavy injections, I went to a recruiting 
station and signed on." In his regiment, he continued the 
injections, but shortly found that he would be unable to 
replenish his diminishing stock of drug. He explained his 
unhappy fate to the corps physician, and was sent to Val-de- 
Grace. He asked to be retired, alleging that he was under 
the influence of a poison when he went to the recruiting office 
and had therefore committed an illegal act. 



Social effects of the war on two drug addicts. 



Cases 101 and 102. (Briand, 1914.) 

Fernand and Emilienne were two recidivists in morphinism. 
Although neither was over 22 years of age, both had been 
several times convicted of shop-lifting. They stole only if 
they had no money for morphine. Prostitution served to 
care for Emilienne, while Fernand was at times a cocaine 
seller, and at times made money in devious ways at Mont- 
martre. Emilienne's patronage scattered with the war, and 
it was the same with Fernand' s. Accordingly, there was no 
money for either morphine or cocaine. Moreover, the shops 
being not crowded were easier to watch. As Emilienne did 
not care to be arrested and sent off as an undesirable, she 
presented herself at the hospital for the insane at Sainte- 
Anne. Fernand shortly joined her there. 



V. ENCEPHALOPSYCHOSES 
(THE FOCAL BRAIN DISEASE GROUP.) 



/ 



Left-sided hemiplegia and aphasia : Contrecoup and 
local lesions. 



Case 103. (Lhermitte, June, 1916.) 

A soldier of 23 was wounded in the left parietal region and 
showed a left-sided hemiplegia with aphasia. The speech 
difficulty, although very marked, retrograded almost com- 
pletely, but the hemiplegia remained severe. This hemi- 
plegia was a spastic one, of a classical nature, with Babinski 
sign and exaggeration of tendon reflexes. Lhermitte thinks 
that the left hemisphere was directly affected by the con- 
tusion, as in point of fact there was an actual loss of bony 
tissue, but that it would not be necessary to suppose the 
ipsilateral hemiplegia was due to an absence of pyramidal 
decussation. The transient aphasia was probably due to 
direct affection of the tissues on the left side of the brain ; the 
permanent hemiplegia was doubtless due to a lesion of the 
opposite hemisphere produced by contrecoup. It appears 
that sometimes a surgeon may be led to superfluous surgical 
intervention in a case of such paradoxical hemiplegia, since 
the surgeon may believe that a bullet or shell fragment has 
traversed the brain substance to the opposite side of the skull, 
when as a matter of fact the brain parts have been injured 
merely by contrecoup. 

Re such amnesia, it is of note that many head cases, even 
if they do not show amnesia, show a conspicuous euphoria 
and lack of understanding of the seriousness of the injury 
in question and of the necessary treatment. According to 
E. Meyer, there are constantly to be found in head cases 
disturbances of perception and lack of coordination (espe- 
cially for time), perseveration, difficulty in thinking and 
calculating. 

133 



J 34 ENCEPHALOPSYCHOSES 



COMMOTIO CEREBRI 

I. Senses: Asymmetrical hyp- or anesthesia (with hyperalgesia and 
osseous hyperesthesia). 

II. Motility: Disorder, muscular or reflex. General or unilateral 
hyperexcitability. 

III. Vasomotor Control: Dermatographia. Cardiac, splanchnic dis- 

order; also, Headaches, Vertigo. 

IV. Emotions: Disorder. 

V. Intake of Ideas: Disorder. Persistent lacunae of memory. 

VI. Intelligence: Disorder of recollective memory. Speech-disorder. 
Intellectual inertia. Overimagination (hallucinations, tremors). 

Mairet, Pieron, Bouzansky. 



Chart 5 



ENCEPHALOPSYCHOSES 1 35 

Gunshot wound of head; alcoholism: Amnesia. 



Case 104. (Kastan, January, 1916.) 

A German soldier had a bullet pass through his right eye 
and lower jaw, leaving a fistulous opening from the mouth. 
He said that he was completely blind, but ophthalmological 
examination cast doubt upon the blindness. There had been 
immediately after the injury a number of severe attacks of 
dizziness, which lasted several hours; and another attack 
developed after he had come back from hospital, to which he 
had gone by reason of his pains. 

He was to be arrested on account of a disciplinary crime 
and had ostensibly gone to his mother's house, there to await 
arrest. The non-commissioned officer found him in a saloon. 
As soon as the phrase, " You are my prisoner ! " was said, the 
soldier lost track of his surroundings. He had drunk a few 
glasses of beer but did not himself think he was drunk at the 
time. He was insulting and violent when asked to proceed 
with the officer, and a policeman was called in to take charge. 
He then lay down in the street and had to be put upon a 
wagon, still firing abusive phrases at his captors. 

Upon examination, aside from the effects of the gunshot, 
excessive knee-jerks and tremors of the body were found. 
The eyebrows met but there was no other sign of bodily 
stigmata. There seems to have been no hereditary disease, 
or any history of severe alcoholism, though the man had been 
convicted previously of violence and theft. The amnesia is 
to be ascribed to effects of the head injury. 






1 36 ENCEPHALOPSYCHOSES 



Bullet in brain : Crises ; cortical blindness ; vertigo ; 
hallucinations. 



Case 105. (Lereboullet and Mouzon, July, 1917.) 

An invalided soldier, 40, was sent to be observed, Oct. 23, 
191 6, because he wanted his pension renewed. He had been 
retired a year before for diminution of binocular vision with 
impaired perspective of objects in the right half of the visual 
field. He had now become completely blind. 

He had been wounded, March 12, 191 5, in the Argonne, 
without losing consciousness. He was wounded at ten 
o'clock at night and waited until the next day to walk to the 
ambulance and was at this time able to see perfectly. Arriv- 
ing at the ambulance he lost consciousness. He was tre- 
phined but remembers nothing about the trephining. 

His memory grew better from his arrival at a hospital in 
the rear in April. An attempt was made to remove the bullet 
in May, 191 5. Though the surgeon's finger was pushed as 
far as the tentorium the patient did not lose consciousness or 
sight, but on leaving the operating room he fainted and, after 
a few days of restlessness and delirium, he became completely 
blind. There was a cerebral hernia difficult to reduce. 
Vision became a little better and light and persons could be 
distinguished at the time when he was retired. A month 
after the operation there was a convulsive crisis beginning in 
the left arm, affecting the legs and ending in unconsciousness. 
Several similar crises occurred in August, sometimes with and 
sometimes without loss of consciousness. Later these crises 
began to be limited to the left side and then to be ushered in 
by visual hallucinations. At home he was unable to care for, 
clothe or feed himself. The crises became more frequent. 
The visual hallucinations began to dominate. 

This situation lasted to February, 191 6, when the blind- 
ness which had been increasing since the onset of the hallu- 
cinations became complete. The crises now became less 
frequent and intense. Headaches not severe were exagger- 
ated after seizures. The patient acted like a totally blind 






ENCEPHALOPSYCHOSES 137 

person and said that he had before him a uniform and con- 
stant gray without any light or dark spots or any color. 
Upon this background bizarre pictures, caricatures, dis- 
guised persons, animals or nameless things appeared colorless 
without relief, in silhouette, but highly suggestive of reality 
to such a degree that at first, according to the patient, he had 
made gestures to reach, or push aside these pictures. The 
crises were Jacksonian. 

Pallor, perspiration, shivering, irresponsiveness, clonic 
spasms of left arm followed. The patient always had a 
premonition permitting him to get into bed if he was sitting, 
for example, in his chair. Sometimes there was a dizzy 
sensation as if the body were being rotated to the left. This 
sensation did not occur at the beginning of the seizure and 
the patient fought against it, turning to the right. Some- 
times he felt as if he were sliding at great speed down an 
inclined plane. Headaches and sleepiness followed, but there 
was never any complete loss of consciousness of memory. 

The eye grounds proved normal and all the photomotor 
reflexes were normal, though there was no pupil reflex to pain. 
The patient could write readily to dictation printed letters. 
It would seem that these printed letters mean that he had 
visual memories, as he traced the characters as if from a 
design. Speech was monotonous with some stuttering; but 
his speech had always been of this sort according to informa- 
tion. He walked with difficulty, not merely on account of 
his visual but on account of his equilibration disorders. 
Outside of his seizures he always turned to the right and if 
left to himself standing he turned to the right. If asked to 
walk straight ahead, he always turned to the right. Silent 
and uncommunicative, he was amiable and sometimes even 
gay. He often had troublous dreams, sometimes seeing his 
relatives. He said he could bring up in his mind the faces 
of his relatives and even the appearance of the Salpeitriere. 
Reflexes and sensations were normal. There was a traumatic 
rupture of the tympanum. Lumbar puncture showed a slight 
excess of albumin and 1.8 lymphocytes to the cubic milli- 
meter. The Mauser bullet was found by X-ray in the left 
calcarine region with its base touching the median line, and 



I38 ENCEPHALOPSYCHOSES 

applied to the inner table of the skull about a centimeter 
above the internal occipital protuberance pointing forward, 
outward, and upward. He was treated on a salt free diet 
with bromides. The seizures grew fewer and at the time of 
report two months had elapsed with nothing but a slight 
vertigo and frequent nightmares. Intellectually also the pa- 
tient had improved. 

The case is one of cortical blindness. The seizures are 
explained by the vicinity of the right Rolandic region to the 
lesion. The rotatory vertigo is to be explained by the con- 
tact of the Mauser bullet with the tentorium and vermis of 
the cerebellum, which may also explain the difficulties in 
orientation that occurred between the crises. The visual 
hallucinations are doubtless due to lesion of the calcarine 
region. 



ENCEPHALOPSYCHOSES 



139 



Tunisian theopath with mystical hallucinations ; gun- 
shot wound of occiput (bullet extracted) : After 
the trauma, Lilliputian hallucinations and micro- 
megalopsia. 



Case 106. (Laignel-Lavastine and Courbon, 1917.) 

A. ben S. was sent to Villejuif with the diagnosis: " depres- 
sion, feeling of impotence, discouragement," having been 
found on the public street. He was indifferent, almost com- 
pletely mute, and was at first considered not to understand 
French. In a fortnight, however, he was talking freely and 
was then found to be afflicted with hallucinations, melancho- 
lia, and delusions, apparently following trauma to the skull. 

A. ben S. might have been about thirty years old, and was 
of a rich family, indigenous in Tunis, well educated in the 
Koran and Arabic literature. 

Upon examination, this Tunisian gunner showed contrac- 
tion of visual fields, poor color vision, and general hypalgesia. 
During examination, the man seized the needle and plunged 
it deeply under his skin, exclaiming that a prophet felt nothing 
and that he could be cut into bits without feeling pain. 

It seems that he had had divine visions from early child- 
hood. In his youth he had once gone to a mountain near his 
home and talked with Mohammed and Allah. Of course, 
Allah did not appear in human form, but he appeared like 
a ball or a wheel of fire, slowly turning. Mohammed was a 
tall man, with a long white beard, his eyes darting rays of 
fire, and his forehead bearing a gleaming bright body. Allah 
was heard talking to Mohammed. Orders were given con- 
cerning the sun and stars. Subterranean treasures were 
displayed, as well as Paradise full of yellow, blue, and green 
houris, transparent, such that, when food was taken, it could 
be seen going down their throats. Hell too was visible, and 
the devil very tall and black, an eye behind and another on 
top. There were also many genii — little men who climbed 
over the Tunisian's body. Sometimes in dreams, Allah 
carried him to all countries of the earth. It was hard to tell 



140 ENCEPHALOPSYCHOSES 

whether these effects were hallucinations or vivid imaginings. 
The Tunisian had been wounded after several months of 
service by two bullets in one day : the one causing an insignifi- 
cant lip- wound ; the other entering the skull behind. After 
several months the bullet had been extracted by trephining. 
His further history was obscured by the fact that he wove 
delusional elements into his story. He said, for example, 
that he had been court-martialed, though there was no 
evidence that this was a fact. It is probable that after his 
wound the patient in a delirium felt that he was going to be 
shot. The visual hallucinations were very interesting, being 
Lilliputian. He would see three or four hundred Tunisian 
gunners walking along, knee-high or taller. Sometimes they 
all would stop and aim at him. He also showed micromegal- 
opsia, real objects changing their height under his eyes. 
Both the Lilliputian hallucinations and the micromegalopsia 
dated from the trauma to the skull. There was no change 
whatever in the mystical delusions concerning Allah and 
Mohammed. These he had before the trauma. 



ENCEPHALOPSYCHOSES I4I 



Meningococcus meningitis with apparent recovery : 
Dementing psychosis. 



Case 107. (Maixandeau, 1915.) 

A soldier in the Heavy Artillery, 42, developed occipital 
headaches and Kernig's sign, December 27, 1915. 

December 31, at the H6tel-Dieu, he showed myosis, slight 
photophobia, meningitic tache, temperature 39.6, pulse 84, 
heart sounds dull. Lumbar puncture: hemorrhagic fluid. 

January 1, the headache was intense, neck stiffness in- 
creased, Kernig's sign less marked; morning and afternoon 
temperature 39.2. Lumbar puncture yielded hypertensive 
cloudy fluid and 30 cubic centimeters of serum were ad- 
ministered. 

This dose was repeated January 2 and January 3, on which 
date there was no headache. 

January 4, Kernig's sign and neck stiffness were dimin- 
ished ; fine rales at the bases without dulness. 30 cubic cen- 
timeters of electragol were injected intravenously. 

January 5, Kernig and neck stiffness slight. Meningitic 
tache; exaggerated knee-jerks; unequal pupils; temp. 36.6 
morning, 39.4 afternoon; respiration 36; pulse 120; no riles; 
splenic enlargement. 

6, no headache or photophobia; constipation; fine riles, 
right base; spartein; meningococci found in hypertensive 
spinal fluid. 30 cc. serum. 

7, more rales; exaggerated heart sounds; intestinal worms 
in stools. 

8, temperature fell to 37; pulse to 90. 

9, patient worse; involuntary stools; Kernig's sign; stiff 
neck; fever. 30 cc. serum injected. 

10, 20 cc. injected. 

11, delirious all night; tetaniform stiffness of neck; more 
rales. 

12, delirious, incoherent words, Cheyne-Stokes breathing. 

13, less stiffness, Kernig almost absent; pupils normal; 
Romberg sign slightly developed; pulse 120. 






142 ENCEPHALOPSYCHOSES 

14, a few rales at right base. 

15, pains in elbows, knees and hands with joint swelling; 
moist rales; temp. 38.4; pulse 140. Digitalon. 

16 and 17, serum erythema of thorax; edema of left knee; 
pulse 150; spartein 16. 

17, ice pack over heart. 

18, edema of knee diminished; no headache, delirium or 
pupillary sign. 

19, improvement. Temperature normal thereafter. 

20 and 21, fine rales. Then all symptoms disappeared. 

Recovery was predicted, but on January 28 it was observed 
that the patient was untidy, made mistakes in dressing, 
such as trying to put his legs into the armholes of his shirt, 
and denied the most evident facts: His kepi on his head, he 
said it was not. Face drawn; skin yellow. Appearance of 
asthenia. Deep depression and hebetude. At this time 
the knee-jerks were exaggerated, pupils unequal, vermicular 
tremor of tongue; the patient walked on a broad base with 
tremulous legs suggesting contracture and weakness. 

February 8, in a similar state the patient wandered about 
his room, moving his bed and chairs about, answering ques- 
tions with an absent air. He had now been taught to be less 
untidy. 

March 5, stiff neck and Kernig's sign were distinct. He 
made believe he was on his farm. Ecchymosis of right upper 
eyelid: he had fallen (his sheep had pushed him over!). The 
improbability of this idea did not persuade him to think it 
had not happened. He walked after the manner of a tabetic. 

In April he became bedridden, unable to walk, with marked 
stiffness and Kernig's sign. He had at this time periods of 
excitement in which he would tear the bedclothes. He was 
invalided as demented. 



ENCEPHALOPSYCHOSES 1 43 

Meningococcus meningitis. 



Case 108. (Eschbach and Lacaze, November, 191 5.) 

During his eleven months captivity at Grafenwohr, Esch- 
bach and Lacaze had the opportunity of observing the case of 
a soldier, 24, who sustained a shell-wound in the left lung and 
was made prisoner August 20, 19 14, at Chateau Salins. He 
got well of his wound, but February 16, 191 5, began to cry 
out and was restless in the night. He was found on the straw 
muttering words among which only the word, "Head, head," 
could be distinguished. He was irresponsive, possibly deaf. 
Suddenly he had a convulsive crisis and whenever touched 
he would have jactitations and cry out. Otherwise, he was 
calm and stuporous. The pupils were widely dilated. In 
short, he showed a mental confusion associated with paroxys- 
mal excitement due to cerebral and cutaneous hyperesthesia. 
The first symptoms had occurred the morning before, when 
he leaned his head against a wall and complained. 

Lumbar puncture yielded intra- and extracellular meningo- 
cocci. The patient was isolated. In the afternoon he be- 
came less agitated, kept his eyes closed, mumbled, repeated 
gestures, would spit in his hands, rub his hands together, rub 
his neck, shoulders and body, or else he would pass his hands 
over his forehead and through his hair. Occasionally he 
would seize the straw and draw it to him with all his strength. 
Once when asked, "What is your name?" he said, "Not 
true. Not true." Hallucinations appeared to have been 
added to the situation. The neck was a little stiff to forced 
flexion. Temperature 37.8. Lumbar puncture under chloro- 
form anesthesia; antimeningococcus serum was injected. 
Next day quieter; able to get up and walk. Slept, mumbled 
less, was able to answer simple questions, desired to urinate 
and finally succeeded. 

February 19, no mental disorder. Headache and lassi- 
tude. Neck, stiff, Kernig's sign marked. Lumbar puncture 
yielded a fluid now puriform; antimeningococcus serum 
injected. February 20, lifting the head produced opistho- 
tonos. Labial herpes. The fluid yielded, besides menin- 



144 ENCEPHALOPSYCHOSES 

gococci, also endothelial cells. Serum injected. February 
21, fibrin in fluid; serum injected. February 22, no head 
symptoms. Herpes more intense, involving also arms. 
Tongue coated. Temperature 37.5, evening 38.3. Febru- 
ary 23, meningococci and lymphocytes in fluid. February 
24, left knee swollen. Serum injected; puncture fluid showed 
meningococci and polynucleosis. Fluid from knee showed 
polynuclear cells without organisms. February 25, patient 
reached evening temperature of 39.5; serum injected. A 
few meningococci, altered polynuclear leucocytes. February 
26, patient rigid, tongue coated, serum injection. Rare 
meningococci, degenerated polynuclear leucocytes. Febru- 
ary 27, rigidity decreased, evening temperature 37.7. Febru- 
ary 28, Kernig's sign absent. Herpes dry. Serum injec- 
tion. Fluid clear; lymphocytes and polynuclear cells; no 
meningococci. March 6, painful inguinal gland on the left 
side. March 7, epididymitis left (mumps two years before, 
with headache two weeks and double orchitis). March 9, 
serum eruption. March 17, epididymitis practically absent. 
Lymph node painful. Later data impossible to get, except 
that there was apparently an arthritis of the hip and a sacral 
decubitus with eventual recovery. 



ENCEPHALOPSYCHOSES 1 45 



Shell-explosion: Meningitic syndrome, fourteen 
months. 



Case 109. (Pitres and Marchand, November, 1916.) 
A soldier sustained shell-shock at the distance of a meter 
at Saint-Hilaire, September 26, 191 5. He lost consciousness 
and blood flowed from his ears. He arrived, September 28, 
at the neurological center in Bordeaux in a semistupor, 
knowing that he had been shocked and had lost consciousness. 
He groaned, cried out, and kept stroking his head with his 
right hand; lay on the right side; showed Kernig's sign right, 
ptosis, and stiff neck. Headache was increased on moving 
and noises. Patient constantly asked for food, but refused 
to drink. Lumbar puncture yielded a yellowish fluid, due 
to laked blood. October 3, headache, ptosis, left internal 
strabismus, temperature 38.5. October 4, lumbar puncture, 
slightly blood-tinted fluid. October 5, improvement; gap 
in memory for period since shock. No strabismus, ptosis 
diminished, temperature normal, improvement continued. 
Kernig's sign and headache persisted. He lay doubled up 
on the right side, eyes closed, right hand on pillow. Defense 
movements on touching the neck or occipital region. The 
condition of semistupor often passed off in the afternoon, 
when he could talk, write or play cards. He had always 
smoked, even at the beginning of his disease. Lumbar 
puncture yielded a normal fluid December 12, 19 15. He was 
sent February 23, 19 16, to a hospital in the country, but 
came back May 9. 

It seems that several days after transfer he had had an 
attack of delirium in the night, having lost consciousness, and 
tried continually to get up out of bed, saying that he wanted 
to go to Verdun to fight. This spell lasted several hours and 
on the days following came mutism, refusal of food, and a 
state of stupor. Nutritive enemata were given. As he grew 
better he sometimes ate a great deal, sometimes nothing, 
even wanted poison from his family, and wrote to a comrade 
that he wanted to commit suicide. 



I46 . ENCEPHALOPSYCHOSES 

May 9, he was clearer, told of seeing the shell, which he 
said he had not heard, nor did he know how he had gotten to 
a hospital. His head and spine had hurt him ever since the 
shock. He had had difficulty in urination for two days after 
the shock. He could not remember the delirious attack in 
the country hospital. He gave various data about his life, 
but not fully. He refused to lie on the left side, or to walk, 
because of pain. He could lift either leg from the bed, but 
hardly both. There was an irregular coarse tremor of the 
extremities. The right hand was weaker than the left; 
there were no reflex disorders ; no change in the eye grounds. 
There was a patchy analgesia. May 26, stupor reappeared 
as before, with semimutism. June, the patient presented 
the appearance of a dementia praecox in stupor, with stere- 
otyped gestures and attitudes, without catatonia. The 
patient was sent to a hospital for the insane at Cadillac. 
November 9, 19 16, he returned to the neurological center, as 
mental and cerebral disorder had disappeared. There still 
persisted a difficulty in remembering facts since the shock and 
there was still a functional paresis of the legs. 

We here deal with a case of a meningitic syndrome follow- 
ing shell-shock and lasting fourteen months. 



ENCEPHALOPSYCHOSES 1 47 



Brain abscess in a syphilitic: Matutinal loss of 
knee-jerks. 



Case no. (Dumolard, Rebierre, Quellien, 191 6.) 

An unmarried subaltern officer, 30, entered an army neuro 
psychiatric center, April 8, 191 5, looking exhausted and bear- 
ing a ticket "nervous asthenia, evacuated for neurological 
examination.' ' He said he had had scarlet fever at ten; 
strongly denied syphilis, of which he presented no trace; 
had not been excessively alcoholic and had had no nervous 
seizures. Detailed information showed that he had been a 
normal child. He left his two years' military service with 
promotion and was a man of above the ordinary intelligence. 

He was wounded in the right buttock with a shrapnel bullet 
about the end of September, 19 14. He went back to his 
regiment two months later and had shared in a number of 
actions up to the time of his evacuation. He said he had been 
very tired for several weeks, and had finally been sent to the 
physician. There were pains in the kidney region and in the 
head, especially on the right side. The head felt empty. 
He could not sleep, but did not dream. Ideas were not 
distinct. Memory had become impaired. He could not 
keep his accounts right, and was afraid something might go 
wrong. 

There was no pain or .nervous or reflex disorder of any sort 
except for the knee-jerks and Achilles jerks (see below). 
A special examination proved complete normality of eyes. 
There was a slight hesitation in words, but no dysarthria. 
There was a slight tremor of the tongue and fingers. 

As to the tendon reflexes, April 9, on waking, the knee-jerks 
were absent, but later in the day gradually came in evidence 
again. The Achilles jerks were also absent at first, but could 
be obtained after a prolonged examination and after percus- 
sion of the calf. In the afternoon, after exercise, the knee- 
jerks and Achilles jerks were easily demonstrable. The left 
Achilles jerk was always a little weaker than the right. 
Massage brought these jerks out to virtual normality. April 



I48 ENCEPHALOPSYCHOSES 

10 and thereafter, similar findings; percussion of the mus- 
cular masses of the thighs and calves always brought out the 
reflexes. 

Lumbar puncture yielded a clear fluid with hyperalbumino- 
sis, 20 cells per c.mm. (lymphocytes and mononuclear cells 95 
per cent) and a positive W. R. Iodide of mercury treatment 
was given April 18. 

April 23, the patient went into a coma, with trismus, stiff 
neck, Kernig's sign r sluggish pupils, incontinence. He was 
transferred to a special hospital, showed on lumbar puncture, 
April 23, 85 per cent polynuclear leucocytes, and died April 
27. The autopsy showed a yellowish, quasidiffluent softening 
of the size of a small egg in the first occipital gyrus on the right 
side. The authors comment on the fact that the only objec- 
tive sign in this case was the variable tendon reflexes of the 
lower extremities, "V unique cri de souff ranee des centres 
nerveux." 



ENCEPHALOPSYCHOSES 1 49 

Early recovery from a spinal cord lesion. 



L 



Case in. (Mendelssohn, January, 1916.) 

Mendelssohn reports a soldier, who was sent to a Russian 
hospital, April 12, 191 5, with a diagnosis of chronic appendi- 
citis. Operated on next day, the patient appeared to be 
passing through a normal convalescence, when ten days later, 
he had an intense headache and some trouble in vision, which 
disappeared the next day, only to be followed, two days later, 
by the patient's complaint that he could no longer urinate or 
rise from bed. 

In fact, Mendelssohn found a complete flaccid paraplegia 
with urinary retention, without fever or pain. Knee-jerks 
and Achilles jerks were absent, and there was a slight exten- 
sion of the great toe on plantar stimulation. There was 
disorder of sensation, with heat sensibility abolished, painful 
points poorly localized, and position sense poor. Electric 
reactions normal. Pain on pressure in and about the lumbar 
vertebral region. Cerebrospinal fluid showed lymphocytosis 
and an excessive albuminosis. 

This paraplegia lasted six weeks. At the end of May, the 
patient began to be able to move his toes and to lift his heel. 
Improvement was gradual and progressive. Early in June 
he could walk if supported. The weak knee-jerk then began 
to reappear and the urinary retention gradually disappeared. 

This patient was not hysterical, although a bit emotional. 
Perhaps, according to Mendelssohn, an organic lesion was 
grafted on a neurosis. Perhaps the spinal lesion was infec- 
tious. At any rate, a presumably organic paraplegia had 
recovered in two months and a half. 



I50 ENCEPHALOPSYCHOSES 



Shell-explosion : Meningeal hemorrhage : Pneuino- 
coccus meningitis. 



Case 112. (Guillain and Barre, August, 1917.) 
An infantryman, 20, came to the Sixth Army Neurological 
Center, October 13, 1916, as a case of "choluria, due to shell 
explosion; epistaxis needs watching." He was somnolent, 
had waked vomiting, pulse 108. Kernig's sign, defensive 
movements of the legs on stimulation, with flexion of leg on 
thigh and of thigh on pelvis, plantar reflexes flexor. Punc- 
ture showed typical meningeal hemorrhage. Two days later, 
temperature 40, pulse 70, that is to say, a bradycardia in 
proportion to the fever. Vomiting, pulse persisted. Next 
day the patient was moaning and semi-delirious and showed 
stiff neck, Kernig's sign, accentuation of vasomotor disorder, 
plantar response flexor with leg retracted, thigh flexion both 
homolateral and contralateral. The spinal fluid upon the 
next day, that is, four days after his arrival at the clinic, 
showed a purulent fluid in which there was an excess of 
albumin, no sugar, diplococci extracellular (proving on cul- 
ture to be pneumococci and able to kill a mouse in twenty- 
four hours) . 

As a rule such hemorrhages remain aseptic, and in facv 
meningeal hemorrhage is said by Guillain and Barre to have, 
as a rule, a favorable prognosis. The above described case 
was the only one of infected meningeal hemorrhage that had 
occurred in the Sixth Army Neurological Center. 



ENCEPHALOPSYCHOSES 151 



ANTEBELLUM cortex lesion: right hemiplegia; 
recovery. Struck by shrapnel on right shoulder : 
Athetosis. 



Case 113. (Batten, January, 1916.) 

A British soldier, aged 27, showed a somewhat remarkable 
phenomenon. It appears that at five years of age, this man 
had had poliomyelitis, affecting the left leg. At 20 years of 
age, he had had pneumonia, and this had been followed by a 
paralysis of the right arm and leg with a loss of speech. The 
man recovered from this illness, although he never quite 
regained full control of the right hand. It is evident that 
this lack of control was not marked, else the man would not 
have been enlisted, and it is Dr. Batten's opinion that at all 
events he could not have shown pathological movements of 
the right hand at the time of enlistment. 

However this may be, in October, 1914, the soldier was 
struck on the right shoulder with shrapnel. Apparently he 
was not wounded, but thereafter he was not able to use the 
right arm well, and in two months' time he had become 
unable to manipulate his rifle. On January 13, 191 5, he was 
sent home. The remnants of the old poliomyelitis of the left 
leg were shown in a general weakness of that leg as compared 
with the right. The movements of the right hand were those 
seen in athetosis. The movements were independent of voli- 
tion. The patient had difficulty in releasing his grasp. He 
improved rapidly during the six weeks he was in hospital, 
although the movements of the right hand never became 
entirely normal. 

In this case, according to Batten, "the stress was sufficient 
to bring into prominence the symptoms due to an old cerebral 
lesion." 






1 52 ENCEPHALOPSYCHOSES 

Hysterical versus thalamic hemianesthesia. 



Case 114. (Leri, October, 1916.) 

A soldier, 40, had been suffering for a number of months 
with pains in the left side of the trunk and feelings of weakness 
in the left arm and leg. In the summer of 19 15 he was on 
leave and while walking, fell, lay down, and found he could 
hardly move his left arm and leg. Two or three weeks later 
he got up, walking with a stick. After some time in hospital, 
he was sent back to the trenches, a little weak. 

He had shortly, however, to be examined neurologically 
again. He could hardly raise the left leg and his passive 
resistance was poor on this side. The left side was almost 
completely anesthetic to all forms of stimulus, although an 
intense faradic current yielded a feeling like that of a fly. 
Nor was the tactile sensation absolutely nil, as it could be 
got with a flat finger on the upper arm and thigh. Cold and 
heat sensations not well localized. The hemianesthesia was 
sharply limited at the median line and affected the buccal, 
lingual and nasal mucosa. Deep sensibility was almost 
abolished on the left side. Stereognostic sense was lost and 
the sense of position was lost absolutely for hand and foot. 

The patient said that he heard less well on the left side. 
There was also a slight contraction of the left visual field. 
The reflexes were lively, but equal on both sides. A diag- 
nosis of hysterical hemianesthesia was apparently called for, 
but psychoelectric treatment failed. The plantar reflex was, 
in fact, completely absent on the left side, as well as the cor- 
neal reflex. The faradic current failed to produce as marked 
a dilatation of the pupil on the left side as on the right. The 
forehead wrinkles were less marked on the left side. The 
mouth deviated slightly to the right. The left nasolabial 
fold was a little less marked. The tongue did not deviate, 
but was a little narrow on the left side. The palate deviated 
a little to the left. The left side of the trunk seemed a little 
less developed than the right, and the scapula stuck a littie 
less closely to the body on the left side, when the arms were 
raised. The left buttock was a little narrower than the right 



ENCEPHALOPSYCHOSES 1 53 

and the left gluteal fold was less marked. In combined 
flexion of thigh and trunk the left foot readily left the floor. 
There was a left-sided hypotonia in forced flexion of the fore- 
arm. There were no tremors of the limbs in repose, except 
a few contractions of the left lower extremity. In movement, 
however, there was a marked tremor and in coordination the 
finger to nose test could not be performed. Speech was slow 
and hesitant, sometimes stuttering. Food was sometimes 
taken into the air passages. Headaches were localized on 
the right side. They had begun when the first symptoms 
began. There was mental disorder, with gaps in memory. 
In short, the case is probably one of thalamic disease, though 
there were no pains except a few in the left side of the trunk 
at the beginning of the disease. The diagnosis of hysteria 
was at first made in this case, but the rule that hysterical 
hemianesthesia is never found without auto- or hetero-sug- 
gestion caused the alteration of diagnosis to thalamic. 






1 54 ENCEPHALOPSYCHOSES 



Shell-explosion: Syndrome suggesting multiple 
sclerosis. 



Case 115. (Pitres and Marchand, November, 1916.) 

A soldier, 40, carriage painter, underwent shell-shock at 
Voquois, May 2, 191 5, following ten hours' bombardment. 
At the time he felt tinglings. The bombardment had just 
ceased when he fainted suddenly while repairing a telegraph 
line. There was no loss of consciousness. He could not 
move his arms or legs, was able to spit, and did not suffer at 
all except for the tingling. He was evacuated to the interior, 
where the diagnosis of psychopathic double paraplegia, Ker- 
nig's sign, zones of anesthesia in the legs, was made. He was 
immediately treated with gray oil, and got an injection of 
neosalvarsan, and iodides. He grew slowly better. He 
could lift a leg from the bed, but then both legs began to 
tremble. The arms had recovered their movement, before 
the legs, but always trembled in movement. 

November, 191 5, he was able to get up; two months later, 
he walked alone. 

At the neurological center, which he entered December 17, 
his gaze was fixed and there was a slight exophthalmos. The 
folds of the face were smoothed out. The nose was deep set 
(as a result of a fall at the age of eight) . In the upright posi- 
tion he could not remain still, but trembled markedly on the 
left side, so that he had to make a few steps to keep his bal- 
ance. He was unable to stand on his left leg. He walked 
on a broad base, in little steps, and rather unsteadily on 
account of tremors augmenting upon movement. General 
muscular weakness; left hand slightly weaker than right. 
He could not lift both legs more than 20 cm. from the bed 
and in the process they both trembled, trembling together. 
There was also intention-tremor of the arms, a little less 
marked than that of the legs, of an irregular rhythm. The 
arms trembled as a whole. In a state of rest there was no 
tremor. There was a slight muscular stiffness and the patient 
himself felt difficulty in relaxing. Patellar reflexes absent, 



ENCEPHALOPS YCHOSES 1 55 

even on reinforcement; Achilles jerks absent. Speech monot- 
onous and tremulous, but not scanning; syllable doubling 
observed by the patient. Manuscript tremulous and, on 
account of tremors, illegible. Hypalgesia of legs, more 
marked distally. Deep sensibility of tendo Achillis and patel- 
lar reflexes lost. Pain on compression of eyes diminished. 
Formication in arms. W. R. of blood negative. Slow im- 
provement followed and the patient left the neurological 
service May 4, 191 6, able to walk more easily and without 
tremor. The knee-jerks and Achilles jerks were still absent. 

We here deal with a syndrome in part that of a multiple 
sclerosis, that is, the intention-tremor, gait disturbance, 
muscular rigidity, and weakness. 

Re multiple sclerosis, Lepine remarks that there are nu- 
merous army cases of pseudo multiple rsclerosis which are 
actually hysterical or hystero-traumatic cases of hypertonus 
and tremor. The true cases of multiple sclerosis, according 
to Lepine, are of interest inasmuch as they are usually found 
in officers. These men have apparently at first but a slight 
motor disorder, quite compatible with desk work. We have 
usually under-rated the cortical element in multiple sclerosis. 
Spells of confusion, delusional ideas, sometimes grandiose, 
start up without warning in these cases. To be sure, alcohol 
and syphilis sometimes also enter these cases etiologically. 
Any case of localized tremor ought to be carefully examined 
psychically, and such cases in general ought not to be given 
responsibility. 



I56 ENCEPHALOPSYCHOSES 



Coexistence of hysterical and organic symptoms 
in two cases of mine explosion. 



Cases 116 and 117. (Smyly, April, 191 7.) 

A soldier was blown up by a mine and rendered uncon- 
scious. Upon recovery of consciousness, he was dumb, 
unable to work, very nervous, paralyzed as to left arm and 
leg. The paralysis improved so that in the hospital at home 
the patient became able to get about. However, he threw 
his legs about in an unusual fashion. Several months later, 
the patient was much improved. 

Shortly, however, there was a relapse. Transferred to a 
hospital for chronic cases, the patient was unable to walk 
without assistance on account of complete paralysis of the 
leg. Insomnia, general tremor, and a bad stuttering de- 
veloped, with a habit of starting in terror at the slightest 
noise. 

Hypnotic treatment was followed by almost complete dis- 
appearance of the tremor. The patient began to sleep six or 
seven hours a night ; nervousness diminished, and the stutter- 
ing slowly improved; but neither the paralysis nor the anes- 
thesia of the left leg was affected by suggestion. The leg 
remained cold, livid, anesthetic, and flaccidly paralyzed to 
the hip. Though a slight improvement has since been pro- 
duced by faradization, the patient still can walk only with 
assistance. 

A man was injured in 1906 by the fall of a heavy weight on 
his back. In 191 4 he went to France as a soldier, and eight 
months later was hurled into a shell hole so that his back 
struck the edge. He was rendered unconscious. Upon 
recovery of consciousness, the right leg was found to be 
swollen, and there were severe pains in the legs and back. 

Since return home the patient had gone from one hospital 
to another, for the most part unable to walk, suffering from 
agonizing pain in the head and eyes, unable to sleep, and in 
the night subject to horrible waking dreams. 



ENCEPHALOPSYCHOSES 1 57 



MINOR SIGNS OF ORGANIC HEMIPLEGIA 

(LHERMITTE) 

I. Hyperextension of forearm (hypotonia). 
II. Platysma sign: Contraction absent on paralyzed side. 

III. Babinski's flexion of thigh on pelvis (spontaneous, upon suddenly 

throwing seated subject into dorsal decubitus). 

IV. Hoover's sign: Complementary opposition (on request to raise 

paralyzed arm, presses opposite arm strongly against mattress). 

V. Heilbronner's sign of the broad thigh (hypotonia). 

VI. Rossolimo's sign: flexion of toes on slight percussion of sole. 

VII. Mendel-Bechterew sign: flexion of small toes on percussion with 
hammer of dorsal surface of cuboid bone. 

VIII. Oppenheim's sign (extension of great toe on deep friction of calf 
muscles; or Schaefer, or Gordon (on pinching tendo Achillis). 

IX. Marie-Foix sign: withdrawal of lower leg on transverse pressure 
of tarsus or forced flexion of toes, even when leg is incapable 
of voluntary movement. 



Chart 6 



158 ENCEPHALOPSYCHOSES 

At first able only to bring himself to an upright position 
and to rush a few steps, he later acquired considerable 
control of his feet and legs through crutches. The insomnia 
persisted. 

Smyly regards this case, like Case 116, as more neurological 
than mental. 

Re organic neurology, much of great value has been re- 
ported. 

Sargent and Holmes say that, contrary to expectation, 
there have been few war cases of bad sequelae of cerebral 
injuries, such as insanity and epilepsy. During early stages, 
after infection of the head wounds, there is dulness and 
amnesia, irritability and childishness, — symptoms which 
disappear during and after repair of the wounds. Mental 
disorder requiring internment is surprisingly rare. During 
12 months only eight cases were transferred from the head 
hospital in a year to the Napsbury war hospital, where cases 
of insanity attributable to the service are sent; and in but 
two of these could the persisting mental symptoms be at- 
tributed to head injury. 

Col. F. W. Mott confirms the opinion of Col. Sargent and 
Col. Holmes, remarking that from all the London County 
Council Asylums, only one case of insanity associated with 
gunshot head wound had been admitted, and that this was 
one of a Belgian who died from septic infection of the cerebral 
ventricles. Yet all cases of insanity in invalided soldiers 
belonging to the London County Council area (about one- 
seventh of the population of the United Kingdom) are trans- 
ferred to these asylums. 

Again Sargent and Holmes point out that both generalized 
and Jacksonian epileptiform seizures are comparatively rare 
in patients suffering from recent head wounds; even con- 
vulsions in later stages have been as yet less common than was 
feared. Thus, after evacuation to England, fits occurred in 
37 (6 per cent) of 610 cases with complete notes, and in only 
eleven of these 37 cases were the convulsions frequent. 
Sargent and Holmes remark, however, that the practice of 
giving bromides regularly to all serious cranial injuries until 
the wound is healed, and for some months afterwards, seems 



ENCEPHALOPSYCHOSES 1 59 

advisable. In 33 of the 37 convulsive cases there have been 
severe compound fractures of the skull, and in four of these 
a missile was still present in the brain. Five secondary 
operations were performed with good results, after drainage 
of small abscesses in two and removal of spicules of bone in 
three. The In-patient and Out-patient records of the Na- 
tional Hospital for the Paralyzed and Epileptic were searched 
for epileptics already discharged from the army, but notes of 
but two patients attending this hospital for epilepsy were 
found. 

As for other neurological complications aside from septic 
infection and hernia formation, there are a few subjective 
symptoms that may necessitate the invaliding of soldiers. 
The most common of these is headache, usually in the form 
of a feeling of weight, pressure, or throbbing in the head, 
which headache is increased by noise, fatigue, exertion, or 
emotion. Attacks of dizziness also occur, and nervousness 
or deficient control over emotions and feelings. Changes of 
temperament are found in some soldiers, who become de- 
pressed, moody, irritable, or emotional, and unable to con- 
centrate attention. 

Foix, under the direction of P. Marie, worked upon aphasia 
in 100 cases, reporting results at a surgical and neurological 
meeting, May 24, 191 6, in Paris. Only lesions on the left 
side of the brain have produced important and lasting speech 
disorder, although lesions on the left side may leave behind 
them a little dysarthria or difficulty in finding words in con- 
versation. It is, of course, hard to tell speech disorder from 
stupor or clouding of consciousness. Foix notes certain 
specialties in speech defect according to which region of the 
left brain is affected. 

First: [Prefrontal lesions produce a transient dysarthria, 
lasting but a few weeks, and right-sided prefrontal lesions 
produce just as much disorder. 

Occipital lesions produce no speech disorder. 

Second: Patients with right-sided hemianopsia due to 
lesions of occipital regions were not aphasic and could read 
or write perfectly. Lesions of the left visual centers certainly 
do not affect reading. If, however, the injury is not to the 



1 60 ENCEPHALOPSYCHOSES 

visual centers, but is upon the lateral part of the occipital 
lobe, then alexic phenomena appear, and these the more the 
lesion approaches the temporal-parietal region. 

Third : Central convolutional lesion produces a variety of 
disorders according to the site and extent of the lesion. 
There is no aphasia with the crural monoplegia due to 
superior paracentral disorder. But slight aphasic disorder 
accompanies the brachial monoplegia of middle central lesion, 
though writing, reading, and calculation are slightly affected, 
and the more so the more the lesion extends posteriorly to the 
stereognostic regions. The lower down in the precentral 
region the lesion appears, the more likely is the Broca syn- 
drome to be observed. But if the hemiplegia is chiefly a 
brachial monoplegia, the aphasic disorder may remain slight, 
involving reading, writing, understanding of words, the 
spoken word, articulation, and calculation. 

jFourth : Lesions of the lateral-frontal region produce more 
or less marked aphasic disorder, just as do those of the in- 
ferior part of the precentral gyrus. This aphasia is more apt 
to occur when the wound is deep. However, no case of 
permanent aphasia has been observed in cases of lesion of the 
lateral-frontal region (termed in Foix's nomenclature, the 
precentral region, but referring to the tissues in front of the 
precentral (or ascending frontal) gyrus of the more familiar 
nomenclature). Almost absolute, or absolute, anarthria fol- 
lows the wound, and the patient is hemiplegic. This hemi- 
plegia may last from ten days to two or three months. After 
a time there is no longer more than a slight dysarthria, and 
writing becomes good again; reading remains, perhaps, a 
little difficult. A complete or almost complete cure is the 
rule. 

Fifth: When the retrocentral region is injured, various 
aphasic syndromes appear. The retrocentral region is the 
parietal-temporal lobe except the superior part of the parietal 
lobe and the anterior part of the temporal lobe, which latter 
two regions when injured do not allow any marked aphasic 
disorder. Lesions of the middle or posterior temporal region 
are particularly important for speech, and produce more 
marked disorder than lesions of the angular gyrus or the 



ENCEPHALOPSYCHOSES l6l 

supramarginal gyrus. At first, words cannot be spoken, for 
a period of a fortnight to three months. Speech returns 
progressively, with an increased power of comprehension. 
At the same time, the patients begin to read and write. But 
there is no further spontaneous progress after a period of 
six or eight months, and then special reeducation must be 
started. These speech disorders of retrocentral (parietal- 
temporal) origin are either aphasic syndromes or slight 
remains of psychical disorders, or again, a disorder practically 
limited to alexia. The true aphasic syndromes concern the 
spoken word, understanding the words, writing, and calcula- 
tion. The disorder is not especially dysarthric and consists 
particularly in loss of vocabulary. It might be called an am- 
nestic aphasia (Pitres). These cases have well-marked intel- 
lectual disorder and their power of calculation is especially 
poor. As to the aphasic traces, which are more important 
to understand than they are extensive in point of fact, they 
relate particularly to calculating power, to vocabulary (slow- 
ness in finding words), and to reading (reading without com- 
prehension). As to the cases of alexia, these are cases of 
lesions of the posterior part of the parietal-temporal lobe, and 
are usually accompanied by a hemi- or a quadrantanopsia. 

To sum up, cases with central lesions (precentral and post- 
central gyrus) have hemiplegia and a Broca aphasia without 
much tendency to cure. Cases with lesions anterior to the 
central convolutions have a transient anarthria and their 
recovery is ordinarily complete. Cases with retrocentral 
lesions have an aphasia suggestive of Wernicke's aphasia, and 
ordinarily leave behind them extensive defects in intelligence 
and language. These cases should be taken account of from 
the standpoint of compensation, since they are much worse 
off for work than many cases with amputations ; and though 
their disorder looks slight, it quite interferes with working at 
a trade. From the point of view of military effectiveness, 
the retrocentral cases are not very good soldiers, and espe- 
cially not good officers, as they do not understand commands 
completely. 



1 62 ENCEPHALOPSYCHOSES 



Neuropsychiatric phenomena in rabies. 



Case 118. (Grenier de Cardenal, Legrand, Benoit, 
September, 19 17.) 

A farmer, 34, mobilized in veterinary work, fell sick at a 
station for sick horses, April 25, 191 7. He breakfasted well, 
drank coffee, and went to the abreuvoir at eleven o'clock. He 
told his mates that he felt bad in his head. He fainted over 
a table at the eating house, refused to eat or drink. At noon 
he went out into the court, vomited and went to lie down. 
A physician thought he was suffering from angina because 
of the pronounced dysphagia. He entered the hospital 
at eleven o'clock at night on the 25th. He was found next 
morning on his back, with a fixed and haggard look, crimson 
face, masseter and phalangeal spasm at times. Respiration 
irregular, interrupted by moans. The pulse would go up to 
120 during agitation and then go down to 50 as soon as the 
patient lay down again. Pupils slightly dilated and unequal. 
As the patient came from a sick horse depot, the first question 
was that of tetanus, suggested somewhat by the jactitation 
of the limbs and the trismus. A violent headache began and 
the patient cried out, " My head! My head!" Painful 
vomiting movements, with very slight bilious material. 
Convulsive movements increased. The pulse was slow. The 
diagnosis " meningitis " was suggested, despite the absence of 
fever and the absence of Kernig's sign. Lumbar puncture 
gave limpid fluid with a normal lymphocytosis, without in- 
crease of albumin or reducing substance. The bacteriolog- 
ical smear and culture were negative. 

Soon another sort of symptoms appeared. The patient 
would rise, cry out, threaten his neighbors. He was calmed 
with morphine. There were periods of excitement alternating 
with periods of calmness, during which he would reply sharply 
but accurately, being somewhat vexed by the questions, and 
would walk up and down without offering a word. When a 
glass of water was offered to him, as soon as his glance met 
the glass his eyes expressed fear. He drew back in repulsion 



ENCEPHALOPSYCHOSES 1 63 

and cried out in terror. When the liquid was out of his sight 
the hydrophobic spasm ceased. This hyperesthesia of the 
sensorium was so intense that the mere sight of the shining 
glassware of the laboratory brought out a sharp crisis. 

He was sent that evening to the neuropsychiatric center, 
walking jerkily and as if slightly drunk, with a number of 
small gesticulations and murmurings. He was immedi- 
ately isolated, undressed himself and went to bed. He did 
not move in his bed, and seemed to sleep. The next day he 
got up, dressed and had a small spell of excitement, but was 
quiet enough on the medical visit, though the floor was soiled 
with urine and vomitus and the clothing was in disorder. 
He now had a pronounced phase, deep sunk eyes, drawn 
features and anxious look; dilated pupils and an expression 
of mixed fear and anger. His breathing was hard and he 
kept his hand on his heart. He was oriented. He suddenly 
rose and said, " I am thirsty." A glass of milk was given 
him. He hesitated a moment, plunged his mouth and hands 
into it and aspirated the drink without making any swallow- 
ing movements. He pushed away the glass, spat a little, and 
vomited a small quantity of a black liquid. Then followed 
an anxious crisis, and he fell upon his side, absolutely immo- 
bile, without breathing for a few seconds. Again in the 
sitting posture, he was taken with contractions of the limbs 
and face. The tendon reflexes were at this time normal. 

A quarter of an hour later the attendant found him dead, 
in the sitting posture, leaning against the wall, mouth open, 
arms dependent, hands extended, pupils dilated — a death 
in syncope. The brain was found congested. There was a 
slight effusion of blood over the posterior aspect of the brain. 
There were no hemorrhages or softenings in the brain sub- 
stance. The muscles were of a dark red to black. The ad- 
herent lungs were very slightly congested at the base. The 
stomach contained a quarter of a liter of black, inodorous 
fluid in which there was much bile and little blood. There 
were numerous small hemorrhages of the mucosa near the 
great curvature. The spleen was large, the liver congested. 
The Pasteur Institute confirmed the diagnosis of rabies. 
There is no history of the man's having been bitten by a dog. 



1 64 ENCEPH ALOPS YCHOSES 

Tetanus: Psychosis. 



Case 119. (Lumiere and Astier, 191 7.) 

A soldier wounded May 18, 1916, was given an ti tetanic 
serum May 26th. The wounds healed, but on June 16, that 
is, 29 days after the trauma, contractures began, at first lo- 
calized. There had been numerous wounds of legs and scro- 
tum by shell fragments and the contractures were limited to 
the right leg and scrotum. There was no trismus or any 
lumbar symptom. 

During the next few days the contractures became general, 
the temperature rose, a shell fragment was found by X-ray 
at the root of the thigh and was surgically extracted. B. 
tetani was found upon inoculation of media with material 
from the shell fragment. Persulphide of soda and anti- 
tetanic serum 90 cc. in three days were given intravenously. 
The temperature fell and the general health was greatly im- 
proved. July 6, hallucinations and terrors, worse at night, 
set in. The man believed himself surrounded by flames, 
that daggers were being plunged into his old wounds, that 
his hair was being pulled. These symptoms lasted a fort- 
night only, whereupon the patient recovered. 

This case and six others accompanied by cerebral dis- 
turbances all recovered, and all the patients retained a per- 
fect memory of their delirium and of their hallucinations. 

The chronological distribution of these cases was odd. 
One case was found early in the war; then no other cases of 
cerebral disorder presented themselves until the group ob- 
served at the end of 19 16. Besides flames and daggers, 
zoopsia was several times observed. One of the cases showed 
these symptoms without having been given antitetanic serum. 

Re tetanus in the war, see in the Collection Horizon a book 
by Courtois-Suffit and Giroux on Les formes anormales du 
tetanos. 



ENCEPHALOPSYCHOSES 1 65 

Tetanus fruste versus hysteria. 



K 



Case 120. (Claude and Lhermitte, 191 5.) 

Claude and Lhermitte describe a condition of tetanos 
fruste. The neck was absolutely rigid. The patient had 
not been wounded in any way and, being regarded as a pure 
neuropath, was sent to the Centre Neurologique at Bourges. 

The differential diagnosis lay between true tetanus and the 
hysterical pseudotetanus or pseudomeningitis. In pseudo- 
tetanus there is a contracture of the superficial and deep 
neck muscles, especially the trapezii, sternomastoid, and 
deep muscles. The condition somewhat suggests that of 
acute meningitis or tetanus, and especially suggests tetanus 
because it is often associated with masseter contracture 
(hysterical trismus). The head is immobile, stiff, and in- 
clined backward; eyes directed above, throat slightly promi- 
nent. Upon attempts to move the head, intense pain occurs. 
The pain and contracture sometimes even suggest a sub- 
occipital Pott's disease. This form of hysterical pseudo- 
tetanus is of sudden onset, as a rule following burial in a 
trench or else contusion, or a slight wound in the cervical 
region. Pressure on the spinous processes produces no pain, 
nor does a blow upon the head; and an X-ray examination 
will definitely eliminate the hypothesis of Pott's disease. 

To return to the Claude-Lhermitte case of limited true 
tetanus: It showed marked modifications in the tendon and 
bone reflexes. Upon percussion of the zygoma, of the occiput, 
or of the clavicle, there was a marked further contraction in 
the contractured muscles. Although there was no apparent 
spasticity in the legs, there was an ankle clonus and a bilateral 
patella clonus, combined with a distinct exaggeration of all 
bone and tendon reflexes. In such cases also there is hyper- 
excitability of the nerves and muscles to faradic and galvanic 
currents. 



1 66 ENCEPHALOPSYCHOSES 



An officer's letter concerning local tetanus. 



Case 121. (Turrell, January, 191 7.) 

The following letter from an officer who had had local 
tetanus [and was treated by Turrell by ionization Dec. 6 
and 7, 191 5, by diathermia Dec. 7 to 22, and occasionally by 
static breeze ionization and chlorine ion to relieve contrac- 
tions from Dec. 29, 19 15, to Feb. 4, 191 6. The tetanus was 
in the muscles of the legs. Of course diathermia is a purely 
symptomatic treatment and does not replace antitoxin serum 
or other specific treatment; thus its effect in relieving the 
contractions of local tetanus is precisely like its effect in the 
treatment of sciatic neuritis or lumbago. 

November 15, 19 16. 
11 Dear Major Turrell, 

" I have been meaning to write to you for some 
time, as I knew you would be interested to hear how I 
was getting on. Your letter has just been received, and 
I am only too happy to give you any information I can 
with regard to my leg. I was wounded in the left leg 
on October 13, 191 5, by high explosive shell, and arrived 
at Oxford on October 22. There was no operation as 
the surgeon in charge did not consider it advisable to 
remove the pieces of shell : my leg seemed to be getting 
better, and after about a month I was able to hobble 
round with sticks. My foot at this time used to swell 
a great deal towards night, and the foot seemed then 
to gradually stiffen up with violent pains at intervals, 
this gradually spread up the whole leg to about the 
knee, and I was compelled to take to my bed again. 
The pain at times was very bad, similar to a very bad 
attack of cramps, and then my leg became rigid and 
stiff, and at other times used to get horrible jumps and 
it was impossible to keep it still, and whenever the doc- 
tor or nurse looked at it it used to stiffen up at once. 
The night seemed to be the worst, and consequently 
I got very little sleep. I often had to get up in the 
middle of the night on crutches to try and obtain 
relief, my leg was so cramped and sore. It was about 
this time that you first visited me and prescribed a 
course of electric treatment for my leg, and I shall never 
be able to thank you enough for the relief it gave me. 



ENCEPHALOPS YCHOSES 1 67 

I cannot remember the names of the different treat- 
ments, but the first one — diathermy, or heat pads — 
certainly relieved the pain, and after the first two or 
three visits to you I got immense relief. I never looked 
back after this, and, although the progress was slow, I 
gradually lost all pain and was able to get sleep at night. 
The nervous jumps slowly disappeared and my leg 
became gradually normal except for contraction of the 
tendons. I was unable to straighten my ankle or knee, 
and it was thought at one time that my tendo Achillis 
would have to be severed. Gradually the knee straight- 
ened and I was able to get my heel to the ground. I 
was for some time on crutches, and was able to leave the 
hospital on February 5, 19 16, walking with sticks. . . . 
I am now able to walk comfortably, but am unable to 
flex the ankle more than at right angle to my leg. The 
circulation is not very good, and I feel anything tight 
round my calf. I am still getting Boards, and have not 
been passed fit for overseas yet." 



VI. SOMATOPSYCHOSES 
(THE SYMPTOMATIC, NON-NERVOUS, GROUP) 



Dysentery: Psychosis. 



Case 122. (Loewy, November, 191 5.) 

Out of a large number of dysentery patients, many of 
whom had very serious symptoms, but one of Loewy's 
patients became psychotic. Loewy in fact had discharged 
this one as normal, and he had been put on the wagon train 
(no opium or alcohol) to go to a sanatorium. As the 
righting shifted, the sanatorium site changed and could not 
be reached with the wagon. Finally, the wagon train met 
the battalion once more and Loewy was told that the man 
was " dying.' ' At this time he was afebrile, without collapse 
symptoms, with a strong and normally frequent pulse, and 
with few signs of exhaustion. Yet the guard had thought 
that he looked moribund. Both upper eyelids were drawn 
rigidly up but conveyed a different impression from that in 
maniacal or anxious conditions. The expression was that 
of staring astonishment, helplessness, and apathetic lack of 
orientation. The patient recognized Loewy, spoke to him 
as " Herr Doctor," said he was doing quite well; he was 
found to be well oriented. There was no fabricating tend- 
ency even as to the number of stools (although Loewy had 
noted such in bad dysenteries of the Shiga-Kruse type). 
He was apparently hard of hearing, as if at the beginning 
of a typhoid fever. He showed a retardation in his intake of 
ideas, and his voice in answering sounded absent-minded. 
There was an expression of absent-mindedness, and the 
patient seemed markedly unconcerned about his health, the 
direction of the journey, the terrible rain, etc. These phe- 
nomena are attributed by Loewy to attention disorder. 

The patient had been out of reach of fire for days. Loewy 
reports the case as one of beginning amentia or as an ex- 
hausted state resembling a Korsakow condition, recalling one 
of emotional hyperesthetic weakness (Bonhoeffer). 

168 



SOMATOPSYCHOSES 1 69 

Typhoid fever : Hysteria. 



Case 123. (Sterz, December, 1914.) 

A soldier entering hospital for typhoid fever, October 2, 
1 9 14, was discharged to another hospital and again, Novem- 
ber 10, to a hospital for nervous disease. The typhoid was 
serious and complicated by delirium. After defervescence, 
the patient was weak and could not stand or walk, especially 
on account of pains and weakness in the left leg. Sometimes 
he had had pains in the sacrum and left hip. He complained 
of tinnitus, deafness, dizziness, headache. He said he had 
fallen from a cart, had been sick for three months, since which 
time he had been under medical treatment for his present 
condition. He had, he said, been given a small pension. 

The gait disorder sometimes amounted to a real astasia- 
abasia. The left leg became stiff and was dragged behind. 
There was a paresis demonstrable in dorsal decubitus, "of the 
left side, especially of the leg, without atrophy. There was 
a hypesthesia of the whole left side of the body, with the 
exception of the head. Hyperesthesia of the left leg, hip 
and upper sacrum. The left corneal reflex was diminished. 
Moody, hypochondriacal, lachrymose. The general attitude 
of the patient was affected and theatrical. Paradoxical 
innervations were frequently found on test. There was no 
neurological disorder except for the absence of the right 
Achilles jerk. 

The absence of this Achilles jerk may be regarded as a 
residuum of the previous accident. The localization of the 
pains points to a neurotic lumbosacral plexus disorder on the 
left side. Superimposed upon this picture are the hysterical 
phenomena. The typhoid fever and its attendant neuritis 
are therefore to be interpreted as the liberating factor for a 
severe hysteria in a subject already disposed to such symp- 
toms through previous accident. 



1 70 SOMATOPSYCHOSES 

Dementia praecox versus post-typhoidal encephalitis. 



Case 124. (Nordman, June, 1916.) 

A butcher, 29 (aunt insane, sister melancholy, one child 
stillborn, deformed), had had several days convulsions at 
eight; went through military service without incident; was 
at the Marne and was evacuated October 19, 1914, with ty- 
phoid fever, — a severe fever with a delirium prolonged into 
the last weeks. Three months convalescent leave was given, 
passed at Paris with the man's aunt, but he had become 
strange. One day he wanted to strangle neighbors of German 
origin; another day departed for Dunkirk and then returned, 
having lost all his documents. 

February, 191 5, he went back to the front, did strange 
things and was soon evacuated to Tarascon. In April he 
went back to his dep6t; May 18, to the hospital at Rennes 
for erythema. June 15, he was given 15 days in prison 
for setting off a cannon too quickly and then running off 
through the fields. August 11, he was interned at Rennes 
for stealing a priest's cap. September 12, two months con- 
valescence. December 10, headaches. Back to Rennes Jan- 
uary 14, February 18, Val-de-Grace, then Maison Blanche. 

Here he was found sometimes sad, immobile; at other 
times laughing and singing. He was very irritable on small 
occasion. Once on leave he had a fugue with complete 
amnesia, though alcohol may account for the latter. His 
memory was vague, especially for his crimes and for recent 
events. He was emotional, indifferent even in the presence 
of his wife or aunt. Sexual indifference. He often com- 
plained of his head, saying that he felt it blocked and that he 
could not think. The headache was frontal and would last 
several hours. The man would, however, not complain 
spontaneously. He was physically, in general, negative. 

This case might possibly be due to a post-typhoidal encepha- 
litis, but Nordman believes rather that it is a case of dementia 
praecox. Perhaps the convulsions at eight produced a slight 
brain lesion, brought to an issue by the typhoid fever. 



SOMATOPSYCHOSES 1 7 1 

Paratyphoid fever : Psychosis outlasting fever. 



Case 125. (Merklen, December, 1915.) 

A Breton farmer, 34, had paratyphoid alpha. Admitted 
to hospital September 3, 191 5, he had headache, anorexia, 
asthenia, coated tongue and tense abdomen, algosuria; later, 
abdominal swelling, borborygmi. in the right iliac fossa, rose 
spots, dicrotism, albuminuria, bronchitic rales. The disease 
was severe, and was complicated by sacral decubitus and 
ran a month. 

At first somnolent, September 8th the patient went into a 
state of mental excitement with agitation and delirium. He 
got out of bed, cried out, sang, talked to his neighbors, com- 
plained that his papers (colis) had been stolen, as well as his 
watch and tobacco; that his horses* hoofs had been injured, 
and the like. 

He grew calmer in a few days, and now no longer tried to 
get up, remaining inert in his bed. The occupation delirium 
persisted — he was not being paid what he owed, and the 
like. He had hallucinations ; looked for scissors, and one day 
said, " Here they are! " At intervals he appeared lucid and 
responded appropriately to questions. 

The fever dropped and the paratyphoid disease appeared 
past, but the mental state remained for three weeks without 
change, having the same periods of lucidity when he would be 
regarded as cured, but falling again forthwith into his post 
oniric ideas. He was soon sent to a convalescent hospital 
and was not wholly well for another month. 



1J2 SOMATOPSYCHOSES 



Psychopathic taint brought out by paratyphoid fever. 



Case 126. (Merklen, December, 1915.) 

A soldier, 31, was a victim of paratyphoid alpha, entering 
hospital October 21, 191 5, with the usual symptomatology: 
fever, asthenia, headache, abdominal swelling, tongue coated 
and red along its edges, diarrhoea. After admission he 
passed into a deep toxic state. 

He woke up in the night with a cry, got up afraid, and re- 
fused to go back into his own bed. He was mute, except for 
curses addressed to the nurses. After two hours he went to 
bed and to sleep. Next day he sat quietly with a depressed 
look, occasionally groaning deeply, talking in brief phrases 
about his anxiety, wanting his wife telephoned to, saying 
that he would not see his children, was going into the four 
planks, and the like. 

This situation lasted about a week. He became afraid of 
medicines and thought he had been poisoned, saying that he 
would rather be shot than poisoned and complaining that, 
though he had served France for fourteen months, they now 
wanted to kill him. In the night time he was agitated. He 
gave vent to cries, and threats, but this delirious state rapidly 
decreased and he became calm the night of September 27th. 
The upper extremities showed a tendency to catatonia. 
From this time forth, during the remaining month, the pa- 
tient was immobile, mute, fearful, and mistrusting, depressed 
and always wore a cunning look. His disorientation de- 
creased and he passed good nights. He would answer 
questions by groaning. He would say, " They think I am 
a Tartar." The end of the mental disorder coincided with 
the cure of the paratyphoid fever. According to Merklen, 
the paratyphoid bacillus in these cases serves to bring out 
a psychopathic taint. This particular patient had always 
been of a sad demeanor, uncommunicative, very impression- 
able and emotional. Two other cases had always been some- 
what below normal. 



SOMATOPSYCHOSES 1 73 

Diphtheria: Post-diphtheritic symptoms. 



Case 127. (Marchand, 1917.) 

A farmer, 37, was evacuated March 20, 1916, for diphtheria. 
April 1 , paralysis of tongue and uvula, impairment of vision. 
These symptoms rapidly improved, but paralysis of the legs 
appeared and then of the arms. This paralysis lasted until 
he was sent to the neurological center June 28 for post-diph- 
theritic paralysis, wherein it was found that voluntary move- 
ments of the legs could be performed, though painfully and 
of slight extent, that walking was impossible, that there was a 
considerable atrophy of legs and arms, that the knee-jerks, 
Achilles jerks and plantar reflexes were absent. There was 
complaint of pains in the legs and over nerve trunks. 

Improvement followed, the atrophy gradually passed away, 
and the voluntary movements of the legs became more ex- 
tensive; but by October the reflexes had not yet reappeared. 
Yet the patient had begun to walk on crutches and soon was 
able to get on with canes only. The improvement did not 
continue. He did not raise his heels and dragged his toes. 
There was now a clonic tremor of the legs as soon as the 
weight of the body was put on them. During movements of 
legs carried on in dorsal decubitus there was found an ir- 
regular tremor of the legs with twisting of the trunk. The 
muscular strength was well preserved. There was a slight 
muscular atrophy. The tendon reflexes had now come back, 
though the right Achilles jerk was weak and the plantar 
reflexes were absent. There was a hypalgesia of the legs 
which ceased sharply at the middle of the thighs. There 
was a slight hypoacusia on the left side. Visual fields nor- 
mal. The patient complained of feelings in the inside of his 
bones. Electrical reactions normal. 



1 74 SOMATOPSYCHOSES 

Diphtheria : Hysterical paraparesis. 



Case 128. (Marchand, 1917.) 

A soldier, 24, was evacuated June 24, 191 5, from Roussy 
for diphtheria and was treated by serum, receiving 80 cc. 
in 8 injections. A few days later there was a paralysis of 
the uvula with regurgitation of liquids from the nose; but 
patient was able to go on convalescence July 21. A few days 
later, however, he noticed that his legs were weak. Vertigo, 
vomiting and painful walking followed, and his convalescence 
was increased a month. The paralysis got progressively 
worse. September 10, he went by automobile to Libourne 
where he stayed two months. He arrived at the Neurological 
Center at Bordeaux November 9 with diagnosis " polyneuritis 
of legs." He could not walk and could hardly flex thighs on 
pelvis or legs on thighs. Voluntary movements of extension 
and flexion of feet and toes were limited. There was neither 
atrophy, pain nor reflex disorder. Both legs were analgesic, 
as was also the abdomen up to the umbilicus. There was 
complaint of dorsolumbar pains and of stomach trouble and 
lack of appetite; vomiting after meals frequent, pulse 120. 

January 3, the patient was able to lift his legs a few centi- 
meters above the bed but not together. There was now a 
slight muscular atrophy especially on the left side. Knee- 
jerks lively, analgesia limited to legs, no vomiting, pulse rapid. 

The patient was sent to a hospital in the country May 8 
to July 8. He was now much better. His legs were able 
to support his body but he could not walk. Slight atrophy 
of left leg. There was hypalgesia now in the feet and legs 
below the knee. There was no pain on pressure over the 
nerve trunks. The electric reactions normal. The patient 
could now walk on crutches. He was invalided on the 
temporary basis, December 12, 191 6. 

It does not appear that in this case the hysterical paralysis 
was preceded by polyneuritis. 



SOMATOPSYCHOSES 1 75 

Malaria: Amnesia. 



c 



Case 129. (De Brun, November, 1917.) 

A soldier lost all memory of his hospital stay in Salonica and 
the voyage home. He could only remember a little about 
the hospital at Bandol. There is a period of transition to full 
memory in malarial cases characterized by sure memory, 
vague on certain points, alternating with phases of almost 
complete amnesia. The soldier in question had very inexact 
memories of the Bandol Hospital, and could only remem- 
ber about his fevers, that they began about noon and ter- 
minated about four o'clock. Twice he had been found in his 
shirt, walking, unconscious, in the passageway of the hospital. 
Having obtained leave for convalescence, three months after 
his memory gap began, he went to Paris, and probably had 
attacks at home. He vaguely remembered afterward being 
carried by automobile to the Pasteur Hospital, December 1. 
There he remained to the end of March, 19 17, without 
preserving anything but the vaguest memories of an inter- 
mediary period of more than six months. The memory in 
these malarial cases often remains permanently altered and 
there may even be a retrograde amnesia, carrying back to 
facts prior to the gap and an anterograde amnesia relative to 
facts after the main gap. 

Thus, there is in the febrile period a retrograde amnesia 
and in the post-febrile period a retrograde or anterograde 
amnesia. One group of subjects are severe cerebral cases, 
and the memory gap appears to run back to a period of true 
mental confusion. But there is another group of patients who 
preserve throughout the febrile period an absolute con- 
sciousness of all acts, and yet the memory gap is just as sharp 
and definite as in the confusional cases. 



176 SOMATOPSYCHOSES 

Malaria : Korsakow syndrome, 



Case 130. (Carlill, April, 191 7.) 

A stoker, 45, was admitted to the Royal Naval Hospital, 
Haslar, November 6, 191 6, from the Fifteenth General Hos- 
pital in Alexandria, to which he had come from a hospital 
in Bombay about three weeks before. At Alexandria he was 
anemic and showed an edema of legs which had been present 
for six weeks. Cylindruria; no albuminuria. At Haslar 
there was no cylindruria and no edema, and nothing but 
weakness, gouty arthritis of left wrist, right ear and left 
great toe. Red cells 4,650,000, leucocytes 10,000 (52 per 
cent polymorphonuclear, 46 per cent lymphocytes). He was 
rather dull mentally. December 10th, Dr. Fildes found 
malarial organisms in the blood on the occasion of a hyper- 
pyrexia (104 ). Quinine was given. December 14th, he was 
transferred neurological. According to the patient's own 
story, he was born June 10, 1868, lived in Fulham, had a 
daughter aged 12 years, had recently seen his wife at the 
hospital: all this seemed plausible enough. 

Later, however, he said that the year was 1899, that King 
Edward was king, that the war was between England and 
some field forces, etc. This well-nourished, pale, simple- 
looking stoker spoke quietly and politely; told about in- 
termittent fever; about being eight years on the active list, 
becoming a reservist and being called up for the war. He 
read intelligently, could do sums, but did not know the name 
of the hospital and was confused about the war. He recog- 
nized that his memory was not as it should be; constantly 
stroked his moustache and chin. He was happy and con- 
tented. 

The gait was normal, systolic blood pressure 140 mm.; 
no evidence of alcoholism. Blood, January 15, 1917, con- 
tained 5,050,000 reds, 10,300 leucocytes (63 per cent poly- 
morphonuclear, 37 per cent lymphocytes). There was a 
bilateral absence of the ankle- jerks, repeatedly confirmed at 
subsequent examinations. Wassermann reaction was nega- 
tive. Puncture fluid contained no cells. 



SOMATOPSYCHOSES 1 77 

Instead of living at Fulham, this stoker lived at Ports- 
mouth, and had not been seen by his wife for four years. He 
had done 18 years' active service and had last sent his wife a 
letter from the Sailors' Home at Bombay, November, 191 6. 
They had been married 21 years. He caused astonishment 
with his wife and friends by announcing that Lord Roberts 
and General Buller were in command at the battle of the 
Falklands. He continued to say that he lived at Fulham. 
He was discharged home, January 22. It seems as if he 
were living through the period of the Boer war. 

Carlill considers that alcoholism may be ruled out, and 
there is no likelihood that the gout was the cause of the 
neuritis. He believes that the neuritis was probably ma- 
larial. Possibly the illness suffered in Bombay may have been 
beriberi or it may have been malarial nephritis. 



178 SOMATOPSYCHOSES 

A complication of malaria. 



Case 131. (Blin, August, 1916.) 

A Senegalese corporal of machine gunners, 21 (early life 
normal save for sore throats and coughing), was a robust, 
well-developed man of 75 kilos when he entered the hospital 
at Konakry, February 15, 191 6. He was given the diagnosis: 
malarial anterior spinal paralysis. 

It seems that he had joined a Colonial regiment, April 8, 
191 5, attended classes as a recruit, left Bordeaux November 
1 for Dakar, arriving there November 11. He stayed there 
some sixteen days, during which time he slept without mos- 
quito-netting. November 16, he left for Konakry, and had 
his first febrile symptoms November 27, with vomiting, 
headache, and prostration. His temperature ran as high as 
41, but by December had fallen to normal, after quinine. 

The corporal was sent away, cured, to his company at 
Kouronesa, December 6. There was more fever, headache, 
and vomiting during the railway trip. Quinine again relieved 
the fever, but a bloody diarrhoea set in so that it was only 
at the end of January that he could go on service. 

February 6, another attack of fever, with shivering and 
perspiration, lasted for some three hours. He could hardly 
stand by himself and had to be helped in walking. Next 
day, another spell of three hours of fever; definite paralysis 
set in, affecting both legs. February 8 the arms were at- 
tacked by paralysis which, unlike that of the legs, was a 
progressive one, attacking first the shoulders, then the elbows, 
the wrists, and finally the hands. All the body muscles were 
in a state of flaccid paralysis, as well as the muscles of the 
face. The patient was now afebrile. February 9 there was 
a slight speech defect; the tongue was slightly paralyzed, 
and swallowing became painful. The jaw movements re- 
mained normal. The muscles of the face were intact and 
the patient could whistle, move his lips, and move his eye- 
balls normally. Vision normal. The pupils were fixed in 
dilatation, more widely on the left side. There was a slight 



SOMATOPSYCHOSES 1 79 

contracture of the vesical sphincter, necessitating the cath/ 
eter. The tendon and cutaneous reflexes were lost. 

By February 14, when the patient was sent to the Bellay 
Hospital, muscular atrophy had made its appearance. No 
Plasmodia could now be found in the blood, which showed 
71 per cent polynuclear leukocytes, 20 per cent mononu- 
clears, 9 per cent lymphocytes. 

This state lasted til February 25. Despite the fact that 
the patient ate well, emaciation rapidly progressed. The 
buttock showed a very few signs of decubitus. Upon this 
date there was pain from a marked orchitis of the left side, 
the cause for which remains unknown (no history of gon- 
orrhoea; catheter used for the last time, February 15). 
The temperature which attended the orchitis came down in 
three days; the patient's appetite was singularly good, but 
the muscular atrophy increased. The speech defect mean- 
time disappeared, and the patient swallowed more readily. 

March 7 a slight and hardly perceptible movement could 
be noted in the fingers of the left hand. Two days later, 
similar movements appeared in the right. March 11 he 
could spread his fingers in a kind of creeping movement. 
Next day slight movements were possible with the legs, and 
March 13 the knees were movable. March 14 the patient 
could lift his head from the pillow. The range of movement 
now increased all over the body. According to the patient, 
those parts were the first to regain power that had been at- 
tacked last. This certainly seemed to be the case with re- 
spect to the left upper limb, in which first the hand and 
wrist, then the elbow and shoulder, successively recovered 
power. The legs regained their power in the same way 
proximad. March 17 the patient could sit up and grasp 
objects with the left hand. The cremaster and plantar re- 
flexes appeared, — the former, more on the right; the latter, 
more on the left. The left pupil remained in wider dilata- 
tion than the right. 

The treatment was by quinin and potassuim iodid, with 
massage. The patient was apparently on the highroad to 
complete recovery, and left for France March 21, weighing 
63 kilos. 



1 80 SOMATOPSYCHOSES 



Trench-foot : Acroparesthesia. 



Case 132. (Cottet, September, 191 7.) 

A fantassin, 36, carpenter by trade, went into the trenches 
October, 19 14, and had two attacks of trench-foot, first in 
January, 1915, when there was a painful swelling of the foot 
and secondly in July, 191 6, when there were some bullae on 
the dorsal aspect of the feet. These were not serious and 
the fantassin did not report sick. 

He was wounded, August 27, 191 6, by shell fragment on the 
right elbow, was evacuated to the ambulance where the 
fragment was extracted and then to a hospital which he 
left cured with a seven days' leave. Although he had not 
suffered in any way from his feet while in hospital, and had 
not been exposed to cold, the bullae reappeared on the feet 
just as they had been in July. They in fact now formed a 
sort of exanthem occupying symmetrically the dorsal sur- 
faces of the toes. The bullae contained serum. They were 
confluent, varying from pin head to a nut in size, were as a rule 
round, but sometimes irregular. The eruption went on to a 
cure rapidly and on the twelfth day the bullae had dried up. 
This patient had hypesthesia up to the knees, hypesthesia 
of the dorsal surfaces of the feet, hyperesthesia of the plantar 
surfaces and ankles, hypesthesia of the forearm and the 
elbow and of the dorsal surfaces of the hands with possibly 
exaggerated sensibility of the palma surfaces. Hypesthesia 
of the face was limited to a small part of the right ear. 
The reflexes were normal and there was no atrophy. The 
name " paresthetic trench acrotrophodynia" was given to it. 

In a service of eighty beds Cottet found within two months 
fifteen instances of these acroparesthetic disorders regarded 
as neuritic changes in trench-foot of a latent and lasting 
character which would have remained unobserved unless 
there were disorders of sensibility. In fact similar disorders 
of sensibility may be found without any history of gelure des 
pieds, forming a latent type of neuritic alteration hardly 
noticed by the patient himself. In twenty-six cases Cottet 
found sixteen with hypesthesia of the ears and of the nose, 



SOMATOPSYCHOSES 1 8 1 



Bullet injury of spine; bronchopneumonia: etat 
crible of spinal cord. 



Case 133. (Roussy, June, 1916.) 

As to the development of eschars, Roussy reports the 
case of a lieutenant wounded September 25, 191 5. There 
was a penetrating wound of the interscapular region. The 
bullet had entered on the posterior aspect of the right scapu- 
lar region and had emerged at the level of the first dorsal 
vertebra. October 1, a neurological examination showed 
flaccid paraplegia, knee-jerks normal, Achilles jerk weak on 
the right, plantar reflexes flexor, cremasteric reflex absent on 
the right, and both abdominal reflexes absent. There were 
pains in the legs and arms. There was retention of urine 
with overflow. A slight dulness on the right; temperature 
from 38 to 39 degrees. 

Four weeks later the knee-jerks had become very weak, 
and the Achilles jerks were now absent. There was an ex- 
tensive diffuse atrophy of the lower leg and thigh muscles, 
and a hypesthesia of pronounced degree had developed 
throughout the legs, over the buttocks, and in the lumbar 
region. Anal and vesical sphincters relaxed; dejections volu- 
minous; sacral decubitus as well as healed eschars. Decem- 
ber 5, the patient was transferred to the Army neurological 
center; temperature rose; there was much expectoration; 
paracentesis yielded no fluid; pneumococcus in the sputum. 
Cystitis had developed despite extreme care. Extensive 
edema of the legs developed. There was increased dulness 
on the right side, coughing and dyspnea. Death, January 

17. 

The autopsy showed a bronchial pneumonia of the right 
lower lobe, confluent, imitating a lobar pneumonia. The 
left lung also showed extensive confluent bronchopneumonia 
at the base as well as disseminated areas and edema of the 
middle and apical portions. Infectious splenitis, large fatty 
liver, swollen kidneys, no pyonephritis. 

The spinous processes of the 6th and 7th cervical vertebrae 



1 82 SOMATOPSYCHOSES 

were injured. There was no obvious gross disease within 
the theca except that there was a slight adhesion between 
the dura mater and the anterior surface of the spinal cord at 
the level of the 7th cervical and highest dorsal vertebrae. 
There was, however, a depression on the anterior surface of 
the spinal cord at a lower level, namely, at the level of the 
4th dorsal vertebra. Microscopic examination showed myelo- 
malacia with small cavities in the 1st and 4th dorsal seg- 
ments, suggesting the Stat crible. 

According to Roussy, these patients injured in the spinal 
region are particularly sensitive to cold and support transfer 
badly even when the disease is short. Such patients should 
be evacuated to the interior after the shortest delay pos- 
sible. Sometimes these patients show rib fractures; these 
are in the posterior portions of the ribs and are due to the 
fall of the man when struck. It might be possible even that 
the spinal lesions should through the action of the sym- 
pathetic nervous system favor lung infection. 



SOMATOPSYCHOSES 1 83 



Shell-explosion : Hystero-organic symptoms ; decu- 
bitus; radicular sensory disorder. 



Case 134. (Heitz, May, 1915O 

A soldier, 32, was bowled over in a first-line trench by the 
bursting of a shell that he did not see coming, September 14, 
1 9 14. He regained consciousness only in the middle of the 
night, finding himself half covered with water. He was 
taken up by the stretcher-bearers at eleven in the morning. 
Paralysis in the legs was then absolute. There were pains 
in the legs and in the back, but there was no evident lesion. 
Knee-jerks, plantar reflexes, and abdominal reflexes absent; 
cremasteric reflex absent on the left, weak on the right. 
Tactile sensations, on the contrary, were almost intact ex- 
cept for a slight diminution over the feet and the external 
aspects of the lower legs. Sensitiveness to pin-prick, how- 
ever, was abolished throughout both lower extremities, and 
diminished in the abdomen and back up to two or three 
centimeters above the level of the umbilicus; that is, in- 
cluding the territory of the first lumbar and the last three 
dorsal roots. Sensibility to heat was abolished in the feet, 
the external aspect of the lower legs, and the posterior as- 
pect of the thighs, but was preserved in the second and 
third lumbar territory, in the anterior aspect of the thighs, 
as well as in the region below the umbilicus. Micturition 
was impossible. Constipation the first few days yielded 
spontaneously September 20. There were signs in the bases 
of both lungs, corresponding with a suffocating feeling. Sep- 
tember 22, he was evacuated, almost well, without signs 
of pulmonary congestion, having regained the power of urin- 
ation and some capacity to move the legs sidewise. Feb- 
ruary, 1 91 5, after evacuation to a hospital at Vic, he showed 
sacral decubitus, soon reaching the size of a hand, as well 
as trochanteric decubitus; traces of albumin in the urine, 
sacral and sciatic pains (recalcitrant to morphine). 

He began to improve December 25. Camphorated oil 
and the sitting posture relieved the pulmonary congestion; 



I84 SOMATOPSYCHOSES 

the temperature, which had oscillated round 38 degrees, fell; 
the decubitus scarred over; the knee-jerks reappeared to 
some extent, and movements began. February 5, the patient 
had become able to walk without crutches. There was 
still a two-franc sized area of decubitus over the sacrum, and 
still a little spinal pain in walking. 

It is difficult to consider this case only functional in view 
of the decubitus, to say nothing of the radicular distribution 
of the sensory disorder. Heitz brings this and the previously 
given case (No. 1) into relation with Elliot's case of tran- 
sient paraplegia (see Case 210) and Ravaut (see Case 201). 



SOMATOPSYCHOSES 1 85 



Shell-shock (windage?) ; typhoid fever; "neuritis" 
actually hysterical. 



Case 135. (Roussy, April, 1915.) 

A Colonial soldier was sent back from the front, Septem- 
ber 12, 1 9 14, for nervous disorder due to the shock of the 
windage of a bullet. He had not lost consciousness. Under 
observation at his station, he got typhoid fever, and was cared 
for at Paris from the beginning of October. About October 
15 he began to feel pains in his left shoulder, neck, and arm. 
The diagnosis, neuritis, was made and was strongly borne in 
upon the patient, so that upon the cure of his typhoid, he 
went out on two months' leave with a complete impotence 
and much pain of the left arm. At the end of his relief, he 
was evacuated to Villejuif. January 24, it was found that 
he had no somatic phenomena whatever, despite the fact that 
the left arm and a part of the forearm was powerless, and so 
painful that the patient cried out when his arm was moved. 
There were a few cracklings in the scapulo-humeral joint. 

Hot air and reeducation cured the man in less than two 
months (March 20), though the disorder had lasted for four 
months. The patient had been retired for hysteria before 
the war and had re-enlisted. 



1 86 SOMATOPSYCHOSES 



Bullet wound of pleura: Reflex hemiplegia and 
double ulnar syndrome. 



Case 136. (Phocas and Gutmann, May, 1915.) 
A soldier, 26, was wounded in the enfilading of an Argonne 
trench December 17, 19 14. He felt the bullet like an elec- 
trical shock, and fell. He had been leaning forward at the 
time and suddenly felt the left half of his body go paralyzed 
and his mouth pulled to one side. He did not lose con- 
sciousness, and spat up a good deal of blood five minutes after 
falling. He lay in the trench all night, unable to move his 
left leg except by the aid of his right. He was evacuated next 
day. There was a five-franc piece wound at the upper border 
of the left scapula, four finger-breadths from the median 
line. There were a few lung signs which rapidly cleared up. 
December 28, the hemiplegia was better, although neurologi- 
cal examination showed weakness of left upper extremity, 
abolition of deep reflexes, and certain skin changes of the 
left hand with edema (main succulent), decreased resistance 
of muscles of lower extremity to passive motion, especially 
of adductors and flexors, exaggerated polykinetic left knee- 
jerk, ankle clonus, Babinski reflex, abdominal and cremas- 
teric reflexes absent on left, platysma paralysis left, with 
complete paralysis in the inferior distribution of the facialis; 
whistling impossible. Also the left eye could not be closed 
singly. Synergic movements of the lower part of the par- 
alyzed face when the right hand of the patient was grasped. 
There were also sensorimotor disorders in the ulnar dis- 
tribution on both sides, with complete anesthesia to pin 
prick. There was also an area of hyperesthesia of the 
anterior and postero-internal aspect of the right forearm 
from below the elbow to the wrist. The tendon reflexes 
were weak but distinct on the right side. The left arm had 
feelings of pain, with elancements and formication from the 
shoulder to the fingers on the ulnar distribution. There was, 
of course, also, local hyperesthesia due to the wound of the 
thorax. 



SOMATOPSYCHOSES 1 87 

Lumbar puncture showed a fluid normal in all respects. i 
We deal with a hemiplegia of organic nature, associated with 
the bilateral ulnar syndrome. The hemiplegia followed the 
trauma immediately. When the ulnar phenomena appeared 
is unknown. 

The lung complications cleared. The pains disappeared; 
motion returned up to the level of the facialis. The patient 
got up and three months later went on convalescence, still 
presenting Babinski, exaggerated knee-jerk and weak arm 
reflexes on the left side. The bilateral ulnar syndrome had 
disappeared six weeks after the patient entered hospital. 
Phocas and Gutmann cite a considerable literature on nerve 
complications of pleural trauma, among them syncopes of 
grave prognosis ; a relatively frequent pleural epilepsy (forty- 
five per cent fatal) or epileptic status (seventy per cent 
fatal) ; and the rare hemiplegia. Accidents and death have 
followed exploratory puncture of the pleura. Air embolism 
is probably not the cause. Phocas and Gutmann prefer 
the theory of a reflex disorder starting from the pleura. 



1 88 SOMATOPSYCHOSES 



Hysterical tachypnoea. 



Case 137. (Gaillard, December, 1915.) 

A man, 23, came to the Lariboisiere November 29, 1915, 
in a hurry to show evidence that he had been invalided for 
valvular lesion of the heart. In point of fact, the interne 
found a murmur at the base. Yet there were things in the 
military papers suggesting caution. The patient next morn- 
ing showed no malaise, dyspnoea, or any evidence of serious 
disorder. The contractions of the thorax beat in time with 
contractions of the alae of the nose, about 112 per minute. 
Here, then, was a cardiopulmonary patient. The heart im- 
pulse was exaggerated; the patient could not or would not 
stop breathing to aid the auscultation, but almost absolutely 
normal sounds could be heard at the apex and the base. A 
valvular lesion could be excluded. The lungs were perfectly 
normal. The patient was requested to stop his gymnastics, 
which might have succeeded elsewhere but could not at the 
Lariboisiere! 

How could the man have established the synchronism of 
pulse and respiration and synchronous tachypnea and tachy- 
cardia? Why should he persist in this form of sport, since 
he had already been invalided? The family history was not 
especially suggestive (father albuminuric, died at 59; mother 
well, probably tuberculous). Scarlet fever at eight; occu- 
pation, tourneur. After four months of service there was 
gastric disorder followed by typhoid fever (despite vaccina- 
tion, according to the patient). Convalescent leave at Paris, 
during which leave he had swollen legs and albuminuria. 
May, 1915, gastric difficulty; valvular lesion determined; 
examination; invalided. At home, a variety of complaints, 
for which treatment was unsuccessful. 

During further examination it was noted that in ausculta- 
tion the head of the examiner was lifted, as if there were 
hypertrophy of the heart or an aortic aneurysm. The syn- 
chronism was less exact on December 2; 112 beats to 128 
respiration. Was this man a simulator? Had he become 



SOMATOPSYCHOSES 



189 



the victim of his own enterprise? There was no evidence of 
simulation. It was a question of a monosymptomatic hy- 
steria. Gaillard discontinued the maniere forte and under- 
took a softer treatment, but the maniere forte had caused the 
family to want to take him away. Perhaps they feared a 
too efficacious treatment. He then escaped observation. 
It is probable that the tachypnoea ceased during sleep. It 
was not so marked after the medical visit was over. 



190 SOMATOPSYCHOSES 

Soldier's heart. 



Case 138. (Parkinson, July, 1916.) 

A corporal, 21, who had been a miner and entirely well up 
to enlistment in August, 1914, went to France in 19 15. In 
June, came shortness of breath and palpitation on exertion; 
later, precordial pain (fifth space, between nipple and median 
line) and giddiness on walking. Like all cases of true so- 
called " soldier's heart," this soldier had no physical signs 
indicative of heart disease, yet reported sick for cardiac 
symptoms on exertion. In this particular case, as in about 
half of forty cases reported by Parkinson, there had been 
no disability in civil life. 

August, 1 91 5, the soldier was admitted to the casualty 
clearing station, where the apex beat was found in fifth 
intercostal space internal to the left nipple line. The first 
sound was duplicated in all areas. The second sound was 
duplicated, though not loudly, at the base. After nine 
months' treatment, this man went back to light duty with 
slight symptoms. 

According to Parkinson, the absence of abnormal physical 
signs in the heart of a soldier should not prevent his dis- 
charge from the army if under training or on active service 
he shows breathlessness and precordial pain whenever he 
undergoes exertion well borne by his fellows. A simple 
exertion test, such as climbing 25 to 50 steps, reproduces the 
symptoms in such a patient. The rate of the heart at rest 
is a little higher than that of normal men, though the in- 
crease on exertion is greater. Nevertheless, it has been 
proved that the increase of rate on exertion bears no relation 
to the symptoms elicited and is therefore without value in 
judging the functional efficiency of the heart. 



SOMATOPSYCHOSES 1 9 1 

Soldier's heart ? 



Case 139. (Parkinson, July, 1916.) 

A sergeant, 36, had been in the army from 17 to 29, but 
in 1908 he had acute rheumatism and was discharged from 
the army. He then became a furnace man and had shortness 
of breath and palpitation on severe exertion with syncope 
three times. 

He re-enlisted in August, 1914, and had an attack of or- 
thopnea and edema after exposure at a review. However, 
he improved and went to France in May, 19 15, where he 
again had symptoms; namely, precordial pain and breath- 
lessness on severe exertion. One day while carrying tele- 
phone wire under fire, the sergeant felt a sudden pain in the 
region of the apex beat, shooting down the right arm. "I 
. thought I was shot." He fell down, very short of breath. 
His left arm remained sore and weak. Two days later came 
a similar attack, this time with unconsciousness, and the left 
arm was now useless. Two days later he was admitted to 
hospital, where slight breathlessness but no pain and no en- 
largement of cardiac dulness could be found. No further 
details are available but it seems clear that this man is unfit 
for duty. According to Parkinson, it is probable that the 
infection indicates the presence of some degree of myo- 
cardial disease. 



192 SOMATOPSYCHOSES 



Strain and shell-shock: Acceleration of diabetes 
mellitus. 



Case 140. (Karplus, February, 191 5.) 

An infantryman, aged 22, previously healthy and from a 
healthy family, was struck by a shell fragment in the fore- 
head and lay for several hours unconscious. He did not 
vomit. He had a number of furuncles on his body and his 
urine, upon examination, showed a severe diabetes mellitus 
which increased despite treatment. Upon an attempt to 
withdraw carbohydrate, the sugar suddenly sank from six 
to four per cent. Acetone at the same time increased. An 
abrasion had been noticed by the patient a few days before 
the shell explosion on the spot rubbed by the tornister. The 
patient said that since his accident he had had to urinate 
every night several times and was often very thirsty, neither 
of which tendencies had he had before. A month before he 
became merod he had had an injury of the hand produced by 
a shell fragment. He had undergone tremendous strain. 

The chances are that the excitement and the strain had 
more to do with the diabetes mellitus than the shell explosion. 



SOMATOPSYCHOSES 1 93 

Dercum's disease. 



Case 141. (Hollande and Marchand, March, 191 7.) 
An adjutant in a chasseur battalion was buried by a shell 
explosion, which killed his lieutenant beside him, January 5, 
191 5, at Hartmannsweilerkopf . Hematuria followed ; ten days 
later, fever with anorexia, and the appearance of two or three 
lipomata on the anterior surface of the thighs. Remaining 
at his post, the adjutant took part in an attack, March 5 ; was 
evacuated on the 8th; " lipomatosis with febrile reactions." 
He spent eight days at Bussang, and thence went to the 
hospital at Pont-de-Claix. Here marked albuminuria was 
noted; the lipomata increased in volume; others appeared 
in the arms. The patient was transferred to the Des- 
Genettes, where the diagnosis nephritis was added to the 
previous diagnosis, and a milk diet was prescribed. Con- 
valescence of five months was proposed. The lipomata 
increased in volume and in number. The patient was then 
hospitalized at Avenue Berthelot, placed in the auxiliaries, 
and stationed eight months at his depot. 

When he was observed by Hollande and Marchand, four 
nut-sized tumors were found on the anterior surface of the 
left thigh; two smaller tumors: one of them painful to pres- 
sure, lay on the inner aspect, another the size of a small egg 
lay in the right thigh, and there were two others on the in- 
ternal aspect and two on the external aspect of the thigh. A 
nut-sized tumor was found on the inner border of the right 
forearm, and below it another lenticular tumor. A nut- 
sized tumor was found on the left forearm below the elbow 
on the internal border. Small tumors were found on the 
buttocks. There were no tumors below the knees, in the 
upper arms, or on the thorax. There were 14 tumors in all. 
The smaller the tumor the more sensitive, and there was 
more pain when the tumor had just appeared and during 
the first days of its growth. There was no spontaneous pain; 
pain only upon a blow or pressure. Diminished knee-jerks, 
especially the right ; no other neurological disorder, although 
the patient complained of often having something before his 



194 SOMATOPSYCHOSES 






eyes. There was a marked diminution in the memory. 
Heart was in the 5th space on the nipple line, pulse no; 
Wassermann reaction negative; red blood cells, 3,520,000, 
white cells, 6500; albuminuria, hematuria, leucocytes, and 
urethral cells in the urine. The temperature had now be- 
come normal. The lateral lobes of the thyroid were slightly 
larger than normal, but not painful. Sella turcica was un- 
changed upon X-ray. Exploratory puncture of a tumor 
showed much free fat, without fatty acid crystals and with 
some fat cells. The cells could not be cultivated in test tube. 
The authors believe it doubtful whether this instance of 
Dercum's disease is related with the shell explosion. 



SOMATOPSYCHOSES 1 95 

Hyperthyroidism. 



Case 142. (Tombleson, September, 191 7.) 
A private, 22, was selected by Col. Garrod for hypnotic 
treatment by Tombleson from among the hyperthyroid 
cases. He was admitted April 3, 191 6, with a typical hyper- 
thyroidism, with manual tremor, enlarged thyroid, pulse 
120, blood pressure 136-40, and hemic murmur. Tombleson 
induced deep somnambulism at the first hypnotic sitting 
and suggested an increase of nerve strength and steadiness. 
The suggestions under somnambulism were repeated for 
ten days. An occasional added suggestion was given as to 
lessening of the thyroid. At the end of the ten days the 
patient declared himself quite well. 

Eight of twenty consecutive functional cases treated by 
hypnotism by Tombleson were cases of hyperthyroidism and 
in virtually all of these an effect like the above was registered. 






196 SOMATOPSYCHOSES 



Shell-shock; thrown against wall, stunned, emo- 
tional: Paroxysmal heart crises six days later, 
observed for two months. Neurasthenia? Mild 
Graves' disease? 



Case 143. (Dejerine and Gascuel, December, 191 4.) 

An infantryman, 29, was sent to auxiliary hospital No. 274, 
for heart trouble, a little thin but looking vigorous enough 
(typhoid fever at 13 and some diseases of unknown nature 
and of brief duration while in military service). 

September 24, a large calibre German shell burst and 
threw him against a wall, producing no wound or contusion. 
He was momentarily stunned, emotionally much affected, 
and noted at the time extreme palpitation. He was evacu- 
ated to Paris September 30, six days after the shock. His 
pulse was 130-134, regular, and the heart seemed not to be 
anomalous in any respect. 

But there were paroxysmal crises in which the pulse rose to 
1 80 and in which the patient fell into a state of great anxiety. 
The mouth temperature in the midst of such crises would 
always rise to 38 , and this temperature would outlast the 
rest of the seizure. The man was mentally depressed and 
apparently indifferent, preoccupied with his heart and his 
insomnia, but at the same time emotionally easily affected. 
In short, he was a neurasthenic. There was no change in 
mental state, tachycardia, or paroxysmal seizures in two 
months, except that he gained weight. Walking and climb- 
ing stairs produced dyspnoea. Urine was negative. Ac- 
cording to Dejerine, such a case should be treated by psycho- 
therapy. 

Alquier, in discussion, called attention to the slight but dis- 
tinct tremor in this case, dermographia, and spells of perspira- 
tion. He suggested that the case might be one of mild 
Graves' disease. 



SOMATOPSYCHOSES 1 97 



Hyperthyroidism three months, following ten 
months' service, at times under protracted shell fire. 



Case 144. (Rothacker, January, 1916.) 

A man in service ten months, under strong excitement and 
at times under protracted shell fire, complained of palpitation, 
insomnia, dizziness, and dyspnoea. Hospital notes showed 
that the left lobe of the thyroid was somewhat enlarged. 
Before the war his neck could not have been very thick; he 
had served his year out without difficulty. His mother is 
said to have suffered at one time from thick neck. Accord- 
ing to the patient, he had never suffered with heart trouble. 
Heart not enlarged; blowing first sound over the apex. 
Graefe, Stellwag and Mobius signs negative. Heart rapid, 
not irregular; pulse strong. There was fine tremor of the 
hands, as well as a tremor of the tongue. Knee-jerks in- 
creased. 

The patient was at first sleepless and excited, but after 
three weeks in bed the heart murmur had disappeared. After 
three months, he was ordered to Ersatz with the left side of 
the neck measuring 20 as against 18 cm. on the right. There 
was a soft pulsating swelling of the thyroid. First sound 
over apex still impure; heart action now regular; pulse 64; 
blood pressure 120 Riva-Rocci; after test exercises, slight 
dyspnoea. No cyanosis. The outstretched hands were no 
longer very tremulous. The knee-jerks were still increased. 
The man had begun to sleep well. His neck was apparently 
much diminished in girth. 

Here then was a case of Graves* disease of acute develop- 
ment, brought out by nervous stress and excitement as 
well as by 10 months of war work and exposure to shell fire, 
— with approximate recovery after three months of rest. 



I98 SOMATOPSYCHOSES 

Graves' disease, forme fruste. 



Case 145. (Babonneix and Celos, June, 191 7.) 
A farmer, 31, entered the Rosendael Hospital, Jan. 25, 191 7. 
He had been two years in active service. The family history 
was negative except that one of his sisters had had dyspepsia. 
The patient denied venereal disease and alcoholism and had 
always been well. At the Battle of the Marne he was slightly 
wounded in the left knee. January, 191 5, he was exposed to 
gas bombs and explosive shells. He was several days in the 
hospital spitting, or perhaps vomiting blood and was sent on 
a long convalescence. On returning to the front, he had to 
be sent back to hospital with a note, " not fit for service, 
nervous troubles and paroxysmal tachycardia." In point 
of view he now showed a number of symptoms suggestive of 
Graves' disease, such as a definite exophthalmia which, ac- 
cording to the patient, started up a short time after the shock 
and a tachycardia (1 10-120) with circulatory excitement, a 
tumultuous heart, neck arteries contracting, almost dancing 
in their contractions, together with a systolic murmur maxi- 
mal in the pulmonary area, not retaining, variable, — in 
short, suggestive of an inorganic murmur. There was also 
a generalized rapid tremor and a variety of vasomotor dis- 
orders, such as blushing and paling, perspiration, exaggerated 
reflexes, emotionality, logorrhea, jactitation. There were 
also digestive troubles, regurgitation after meals and the 
patient had become thin and weak. 

There was, however, no swelling of the thyroid gland nor 
any eye signs other than the exophthalmia. In short this 
case is doubtless one of the forme fruste of Graves' disease. It 
seems to show that Graves' disease may have a traumatic 
origin. 



SOMATOPSYCHOSES 1 99 

Somatic complication in a shell-shock hysteria 
(Trauma). 



Case 146. (Oppenheim, February, 191 5.) 

Musketeer. No faulty heredity, but was always somewhat 
nervous. On October 26, a shell burst one meter in front 
of him, burying him under the anterior wall of the trench. 
He was dug out and taken to the field hospital, where he 
remained unconscious until the next morning. On October 
29, he was taken to the reserve hospital. Severe pain in the 
head, entire scalp tender on pressure, especially in the left 
frontal region, left side upper lip swollen, bluish and dis- 
colored. Left tenth and sixth ribs broken. Fracture of 
skull (?). November 10, at eight o'clock at night, sudden 
attack of vomiting, and the patient was found in a faint in 
the water closet. Almost complete paralysis of speech and 
all of the four extremities. Consciousness obscured; no 
sensory disturbances. November 11, severe headache and 
vertigo. Speech somewhat more intelligible. Pulse, 60 to 
68. " Evidently secondary hemorrhage in the brain." No- 
vember 12, to Augusta Hospital. November 20, admission to 
nerve hospital. Typical aphonia. Limitation of motion in 
all four extremities, but no paralysis — anergy. Reflexes 
normal. Unable to stand and walk. Sensibility preserved. 
Under suggestive treatment, curative gymnastics, as well 
as electrotherapeutics, the aphonia and abasia disappeared 
in a few days, but the patient continued to complain of head- 
ache and insomnia. December 16, an attack of nausea, 
headache, vomiting, loss of consciousness, followed by epi- 
staxis, marked tachycardia. January 4, in his sleep he felt a 
prick in his left upper arm, as if he had pushed a sewing 
needle into the arm. X-ray examination showed a needle 
in the arm. This was extracted under local anesthesia. 



VIII.* SCHIZOPHRENOSES 
(DEMENTIA PRAECOX GROUP) 



The Sisters ear boxed for blow to a German soldier's 
pride: Diagnosis PSYCHOPATHIC CONSTITU- 
TION! A true psychosis develops : hate of Prussia 
and the Junkertum: Diagnosis, DEMENTIA 
PRAECOX!! 



Case 147. (Bonhoeffer.) 

A sick soldier in a military hospital kept complaining of 
being waked up too early, and of poor food. His reactions 
looked like the irritable weakness of a psychopath. One day 
he went into a room where a woman was being examined, 
without knocking. When ordered out, he boxed the Sister's 
ear. 

He said himself, on transfer to the psychiatric clinic, that 
he had always been quarrelsome as a child with his brothers 
and sisters, subject to fainting spells, and poor and stubborn 
in military service, — all of which seemed to clinch the diag- 
nosis of psychopathic constitution. 

But he seemed to show a decided lack of autocritique. 
About boxing the Sister's ear on her saying " Please go out," 
— his idea was that he could not let a thing like that happen 
to him, — a German soldier and a patient! Moreover, "It 
should not be thought that perhaps I had a love affair with 
her! There was a cynicism about her." The Sister had a 
strong sex impulse, he could see that by her nose: she was, 
so to speak, " hypochondriacal." Both in speech and writ- 
ing he used stilted phrases. The ego at last swelled to the 
point of his saying that he was an inhabitant of the World 
and hated Prussia and Prussian Junkertum. 

Then came unmotivated states of excitement, with pressure 
of speech and motion, and eventually negativism. Accord- 
ingly, the diagnosis hebephrenia finally replaced that of 
psychopathic constitution. 

* VII. Geriopsychoses (senile-senescent group) not repre- 
sented in war cases (see page). 

200 



SCHIZOPHRENOSES 201 



Dementia praecox, arrested as spy. 



Case 148. (Kastan, January, 191 6.) 

A German private, called to the colors, was supposed to 
take his civilian clothes to the post office along with his 
comrades on March 21, 191 5. He did not get his package 
ready in time and was ordered to go with another troop. At 
an opportune moment, he left the barracks with the package 
of clothing. When later arrested, he said that he had gone 
by railroad to Dirschau; then he had visited Berlin. After 
this, he had walked to Bromberg, Schneidemuhl, and Lands- 
berg. 

At last he had ridden back to Kustrin. At Kiistrin some 
children told a railway official that the man was making 
drawings. There was a petroleum tank near by. Accord- 
ingly, he was arrested as a possible spy. He claimed that 
he was not a soldier. 

In the clinic, he looked dull and smiled a good deal. It 
seems that, before being called to the colors, he had been very 
angry with his wife and had even threatened her. He now 
explained this anger as his wife's fault. She had attacked 
him, he said. He said that he sometimes had attacks of 
weakness, which used to last two days at a time, but they had 
recently lasted for a shorter time. He said that his thoughts 
always wanted to be somewhere else. In fact, he had not 
performed military duty. His uniform had been gotten for 
him, but he had had no further orders. Sometimes in a fever 
or dream his head seemed to be as big as a room, as if there 
were no space for it. There was an itching in his legs, he 
said, which often fell asleep so he could not stand on them. 
He had had syphilis seven years before, after which he had 
been hoarse, forgetful, and anxious. 

Examination showed perceptive power and knowledge to be 
good. He played the violin, but always the same tunes. 
He said that he had not worked in Berlin during the winter 
of 1 9 14. He spoke as if he had been in another sanitarium, 
where he did nothing but dream by himself, taking no in- 



202 SCHIZOPHRENOSES 

terest in things, and lying indifferently, with a blanket over 
him. 

He said that when he received the uniform he had a long- 
ing for clean underclothes. Requested to explain the mean- 
ing of the uniform, he remarked: " Why, many have these 
things on." 

Re dementia praecox, Lepine states that in the French 
army instances of dementia praecox have been numerous in 
the interior, both at the time of mobilization and at the 
time of calling out sundry new classes. He notes that the 
courtmartial and invaliding experts have neither the leisure 
nor the experience necessary to keep these men from going 
into the army. The somewhat frequent remissions in de- 
mentia praecox make the task all the more difficult. To be 
sure, the stuporous and catatonic cases are not very much 
in evidence in the army ; when such cases do occur, it is easy 
enough to evacuate the patients to a hospital for observa- 
tion. Far more troublesome are cases of a less advanced or 
milder nature. Here are cases in which judgment is deficient, 
and in which quite unsystematic, incoherent, and transient 
delusional ideas occur. The patient looks quite normal to 
the non-psychiatric expert. Something odd happens which 
quite suddenly reveals the delusional ideas. For example, 
there is a fugue, or else the soldier goes to his superior and 
aggressively chides him for having troubled him the night 
before. These particular psychopaths are among the most 
dangerous to be found in the army. 



SCHIZOPHRENOSES 203 

U 

Fugue, catatonic. 



Case 149. (Boucherot, 1915-6.) 

A gunner, aged 23, enlisted on the expiration of his regular 
period of service and was a good soldier, in excellent health, 
up to June, 191 5. He then began to have a few vague ideas 
of persecution. In a short time these became more definite 
and he caused talk by requesting to go into another corps 
because his comrades did not like him. He told his brigadier 
that the soldiers were frightening him by magnetism. He had 
hallucinations of hearing people say, " He will get it." He 
kept by himself, would not eat and stood motionless for 
long periods of time before his mess-tin. He was often found 
in a dreamy state of apathy. One day he left the cantonment 
without leave, wandered through fields, had coffee in a village 
and then started off in no special direction. The police 
took him without resistance the next day. He said, " My 
comrades are in politics; they are going to cheat me." He 
was brought to Fismes and the ambulance surgeon said 
that he found he did not know what he was about. He was 
amnestic for the fugue, explaining that he went because he 
was frightened. It was hard to get him to eat. 

July 14, he was evacuated to Fleury protesting arrogantly, 
but this phase of excitement passed and he became absolutely 
indifferent and disoriented. He became untidy in his person 
and in no way could his attention be attracted whether by 
mentioning his family or the war. He sometimes made ape- 
like grimaces and sometimes laughed causelessly. He was 
occasionally negativistic, but in general was perfectly com- 
pliant with the requirements of the hospital. Now and then 
he started off impulsively to escape but was brought back 
quite indifferent. Now and then he went into bizarre con- 
tortions on a medical visit or aped gestures of bystanders. 
He began then to go into stereotypical attitudes. This case 
is the only catatonic one found by Boucherot in his war 
group. 



204 SCHIZOPHRENOSES 



Desertion: Schizophrenic-looking behavior. Ad- 
judged responsible. 



Case 150. (Consiglio, 191 5.) 

An Italian private in the artillery, a telephone operator 
at the front, came up for desertion in the face of the enemy. 
It seems that he had often left his post, going off for a number 
of hours and drinking. At last he lost his position in the 
battery, went off and got drunk again, and was removed to a 
hospital and held as a neurasthenic and psychopathic pa- 
tient. At the territorial hospital he was regarded as a melan- 
cholic. He still showed signs of alcoholism, was hallucinated, 
did a number of peculiar things, was impatient of medical 
examination, and was given a furlough of two months for 
convalescence. He apparently grew somewhat better in 
his father's home, but went to a physician there and presented 
his certificate as a mental case. His behavior was so 
peculiar on subsequent arrest that he was sent for obser- 
vation to Consiglio. 

It appeared that he had been in military service from 
August, 1 91 2, and had been imprisoned for a space of eight 
weeks for disobedience when he had been in military service 
for six months. He had been punished in the army nine 
times, once being given 70 days for lying. He was regarded 
as an undisciplined soldier but not as a nervous or mental case. 

At hospital he was in a semi-stupor, claimed that he was 
forgetful, was apathetic concerning home and relatives, com- 
plained of pain in the head, and altogether preserved a 
strange and stolid attitude with occasional gestures, mimicry, 
and stereotyped reactions. As he had come to be operated 
upon, he looked about for the cannon that was to be used in 
the operation. Accordingly the question of dementia praecox 
might well be raised. 

His indifference turned out actually to be assumed and 
pretentious. He preserved throughout an arrogant tone, and 
there were features in his voice that strongly suggested simu- 
lation. 



SCHIZOPHRENOSES 205 

According to Consiglio, we are dealing with an epileptic 
degenerate, addicted to alcohol, lying, and immorality. The 
question concerning responsibility was settled in the affirm- 
ative. Of course, it might be thought that the case was 
one of pathological intoxication, in which case, the man might 
be regarded as only semi-responsible. However, the phenom- 
ena of simulation, not merely in the observation hospital but 
also in the period of apparent depression and strange con- 
duct immediately following his arrest for desertion, led to 
the decision that the man, despite his nervous abnormality, 
was responsible for his act. He was condemned to 20 years 
in prison. 

Re dementia praecox, Buscaino and Coppola found a num- 
ber of cases of dementia praecox amongst soldiers admitted 
to hospital during the period of mobilization; cases amongst 
men who had not yet been at the front. These mobilization 
cases, in fact, were as a rule either cases of dementia praecox, 
cases of a psychopathic constitution, or cases of alcoholism. 



206 SCHIZOPHRENOSES 



A disciplinary case : Schizophrenia, alcoholism. 



Case 151. (Kastan, January, 1916.) 

In October, 19 14, a German soldier returned to his barracks 
late from a drinking bout. He insolently called for order, 
brandishing his arms, and when the captain rebuked him, he 
kept a cigar in his mouth. Examined in hospital (Allenberg), 
he was very reticent at first but wrote his name up over the 
bed with the additional word "Dead" He answered, " I 
don't know " to most questions. Although it was December, 
he said the season was summer. He was to be shot for 
disrespect, he said, but showed more disrespect at every 
remonstrance. " What is your regiment?" " I am no sol- 
dier at all, you know. I have already been discharged as 
unfit for service." " Have you been in prison?" " I don't 
know. My father often thrashed me." Then suddenly, 
after a moment, " I was in prison five, seven, and two years, 
and my father was in prison four, six, and three years." He 
said that he had drunk ether and urged the physician to try it, 
as one saw all sorts of beautiful pictures and figures and heard 
music. 

Upon investigation, it was found that the man had been 
in a provincial sanatorium for some form of degenerative 
mental disease with excitement. He, at this time, had given 
a number of fantastic stories concerning his wanderings. 
For example, he said he had come from Australia, where he 
had eaten snipes and crows ; that he was on his way home and 
would get there in half an hour (real distance 10 hours). 
Or again, he would roll his eyes, assume a false name and say 
that he had come from Morocco, or that he was the emperor 
and would not play soldier. When asked to repeat digits, he 
habitually omitted the last digit. He had been a poor scholar, 
and of a tricky and treacherous character. 

Despite this history, he had behaved well in the army at 
first, though insolent to superiors. On July 5 he had a heavy 
drinking bout, and wrote next day to his mother that he was 
going to commit suicide. At this time he had been put for 
safe keeping in a cell, where he saw foxes making as if to bite 



SCHIZOPHRENOSES 207 

him. He also said that he was a rich nobleman, a cavalry 
captain with a servant (asked to be given his pressed clothes 
and his cigarettes), and was being pursued. He rode his 
pillow as if it were his horse, and hid it in the horse's stable, 
namely, the bed. He ate nothing, as he thought everything 
was poisoned ; smeared himself with faeces and drank urine 
as " strawberry punch." 

We are evidently here dealing with a psychopath of schizo- 
phrenic tendencies, strongly colored, however, by alcoholism. 
The patient's father was a drunkard, and a brother and 
sister were insane. 

Re schizophrenia in the German army, Saenger remarks 
that like paresis, so also latent dementia praecox becomes 
acute under war conditions. E. Meyer states that amongst 
1 126 officers admitted to his hospital, August I, 1915, there 
were 352 that had either psychoses or neuroses, amongst 
which were 148 psychogenic cases (either psychopathic or 
hysterical), 128 with what he terms a congenital psycho- 
pathic diathesis, and 76 with traumatic neuroses. The 
cases of congenital diathesis were somewhat difficult to diag- 
nose, since but 44 of these were clearly psychopathic and in 
the remainder the question of dementia praecox or of cyclo- 
thymic conditions arose. 

Stier gives statistics for 1905 and 1906 in the German 
army, namely 35 per cent of dementia praecox cases. Under 
war conditions the army has developed far fewer cases: 
Bonhoeffer, 7 per cent; Meyer, 7.5 per cent; Hahn, 13 per 
cent. But although dementia praecox figures so much less 
frequently in the mobilized army than in the army of peace 
times (manic depressive psychosis is also less in evidence 
under war conditions), the psychopathic constitutions, hys- 
terias, traumatic neuroses, and the like, run from 17.5 per 
cent (Stier, 1905-1906) to 54 per cent (Bonhoeffer), 37.5 
(Meyer), 43 per cent (Hahn). 



208 SCHIZOPHRENOSES 



Schizophrenic symptoms. Aggravation by service. 



Case 152. (De la Motte, August, 1915O 

A Landsturm recruit, 20, and somewhat peculiar in early 
life, got whipped by his comrades for getting back too late from 
leave. The next day he was commanded to carry a machine 
gun. He threw the gun down and made for the barracks. 
He was put under psychiatric observation, as he said he did 
not know what he was doing. His conduct seemed normal 
at first and he explained that he had heard noises and sing- 
ing in his head, — pointing to the left ear where there was an 
otitis media. His skill, knowledge, and general experience 
seemed well in hand. However, he was not very communi- 
cative. Eventually a series of schizophrenic symptoms came 
to light. He had been hearing threatening voices of varying 
intensity for two years, sometimes a veil seemed to be before 
his eyes, sometimes he heard his thoughts, and felt that his 
whole personality was changing. He began to think that 
his facial traits were gradually turning into those of the 
physician. The hallucinations were so insistent that some- 
times he did not know what he should do. He was evidently 
unfit for military service, and the decision was also made 
that the mental disease had been aggravated by service. 

Re schizophrenia in the service, most authors point out 
that there was either patent or latent schizophrenia before 
mobilization. E. Meyer attempted to make a study of the 
influence of the war on psychopaths. He found that the 
ego of the psychopath remained relatively unaffected by the 
war. Naturally, the paretics and the seniles were unaffected. 
The grandiosity and self-centredness of the alcoholics re- 
mained as prominent as ever. Seventeen schizophrenic cases 
were studied, and some of these yielded entire apathy with 
respect to the war; others had the content of their delusions 
somewhat affected. Saaler remarks on the military tinge 
which dementia praecox assumes under war conditions. 
Dementia praecox and manic-depressive psychosis alike show 
war changes. 



SCHIZOPHRENOSES 209 

Shot himself in hand. Delusions. 



Case 153. (Rouge, 191 5.) 

An infantryman, 26, left for the front August, 1914, was 
slightly wounded, recovered, went back to the front, and then 
is said, in March, 1915, to have shot himself in the hand. 
When up for military review a delusional state set in. It 
seems that he had been interned in several hospitals for ex- 
amination, but escaped four or five times because physicians 
wanted to poison him and had partially succeeded. 

He came to the Lemioux Custodial Institution, July 12, 
19 1 5. His brother, 15, was a voyou; his sister, 16, was an 
imbecile. The patient told about his military history and 
how he had shot himself in the left hand, to be with a certain 
woman, how attempts had been made to poison him, espe- 
cially a certain man in Bordeaux, who wanted to possess the 
woman in the case. In point of fact, the physicians could 
not save him from this enemy. 

The patient now became calm and indifferent, lived se- 
cluded and almost immobile. In November, however, he 
began to sit down and eat like others, making low, timorous 
answers, vague and confused. He smiled cheerfully on 
questioning, but had many sad ideas. He would smilingly 
say that he was going to die soon. 

Re schizophrenia in the French army, Boucherot found 
eight cases amongst 107 soldiers admitted to Loiret in the 
first year of the war. He remarks upon the fact that the 
schizophrenic cases were often disciplinary. The group is a 
disciplinary group. Damaye remarks upon the difficulty of 
diagnosis betwixt feeblemindedness and dementia praecox 
as observed in the French army. 



210 SCHIZOPHRENOSES 



Volunteer : Dementia praecox. 



Case 154. (Haury, 1915.) 

N. enlisted voluntarily for three years in the Infantry, 
September 10, 1912, and immediately gave indications of 
abnormal mentality by his conduct. He made mistakes all 
day long. At reveille he had to be called several times, and 
when his corporal objected, he said, "It is cold; I don't see 
why I must get up; I am free to remain in bed until 8 o'clock." 
In reply to his corporal's remonstrance about his continued 
latenesses, he once said, "I can't get ready; I have no 
mirror to wash before." This was rather surprising conduct 
from an intelligent printer-engraver, who had lived and gone 
to school in the town of Lyons. He was unable to make his 
own bed or to perform the simplest of exercises in the manual 
of arms. He was violent on several occasions, once attack- 
ing a comrade who had given him an order, and again when 
another had taken his place in the line. His reasoning 
faculties were those of a young child. He continued doing 
these strange things, and was finally discharged. 

Re dementia praecox amongst American troops, Edgar 
King, before the war, concluded that some 5 to 8 per cent 
of the American cases of mental disease in the army belonged 
to the paranoid form of dementia praecox. King lays spe- 
cial emphasis upon dementia praecox, finding that more than 
one-half of the army admissions for mental disease belong 
to this group. He calls attention to the number of deser- 
tions and undesirables in the group. He found that 70 
per cent of the cases showed some heredity. 



SCHIZOPHRENOSES 211 



Hysteria versus catatonia. 



Case 155. (Bonhoeffer, 1916.) 

A reservist, 31, was in the hospital about Christmas, 1914, 
for rheumatism, when suddenly he became excited and was 
sent to the Charite Psychiatric Clinic. He was restless all 
night, moving about in bed, grinding his teeth, and contin- 
ually getting up. He had a blank and astonished expression ; 
his breathing was rapid and forced. There were no py- 
ramidal tract symptoms, but muscular power was dimin- 
ished, — more on the right than on the left. While the 
knee-jerks were being tested, the legs moved (seemingly 
psychogenic). Irregular hypalgetic zones were found, and 
pain was less well felt on the right side than on the left. 
Answers to questions on mental examination were made with 
the appearance of effort, the patient breathing deeply and 
rapidly, head drooping, forehead wrinkling, and eyes glanc- 
ing about in an astonished way. "How many legs has a 
horse? " After long cogitation, the man counted slowly, 
— 1, 2, 3, 4. " What's your wife's name?" " Marie — 
Marie, I think." 

In the interpretation of this case, the functional paresis 
and hypalgesia of the right side, the functional pseudo- 
clonus obtained during the knee-jerk test, the mental situa- 
tion, — rather suggestive of a hysterical pseudodementia or 
a "Ganser " dazed state, — make the probable diagnosis at 
first sight psychogenic. Left to himself, however, the pa- 
tient assumed a stereotyped unchanging posture; he would 
suddenly cry out, without particular emotion, that he was 
to be shot or executed; there was a tendency to rhythmic 
repetition of certain answers to questions, with the suggestion 
of perseveration. 

After a time, pronounced rhythmic, and then stereotyped, 
movements started in. Suddenly negativistic phenomena, 
with refusal of food and self-accusatory ideas set in; speech 
stopped altogether. Information from his relatives showed 
that he had been peculiar for some time and had for years 
occasionally said that he was going to be shot. 



212 SCHIZOPHRENOSES 

Here then, instead of a hysterical pseudodementia, was a 
case of hebephrenia or perhaps catatonia. Possibly there 
had been no pseudodementia, but actually an elementary 
disorder in the associative process. Possibly the defects 
which the patient early showed, in his responses, for example, 
were really genuine schizophrenic blocking. 

According to Lewandowsky, almost all cases of neuras- 
thenia, of hysteria, and of the so-called traumatic neuroses, 
stand out very clearly as functional. Bonhoeffer is far less 
certain that the diagnosis can be made readily in all cases. 
Antebellum conditions have not been continued in war- 
time; hysteria was a female affair antebellum, but under 
war conditions, it is found necessary to draw many differ- 
ential diagnoses in the male betwixt schizophrenics, epilep- 
tics, and psychotics, on the one hand, and hysterics on the 
other. 

Re the so-called Ganser symptom, Hesnard has dealt espe- 
cially with the value of what he calls the symptom of " ab- 
surd answers," finding the differential diagnosis between 
dementia praecox and simulation particularly difficult. 
Hesnard states that incoherence is very hard to simulate. 
The answers of the Ganser patient are not always incorrect, 
and not always absurd. The patient strikes one as intact 
except for the absurd answers; intimidation and other ex- 
ternal conditions affect the symptom greatly. Drugs are 
refused by the Ganser patient. 



SCHIZOPHRENOSES 213 

" Hysteria " — actually dementia praecox. 



Case 156. (Hoven, Henri, I9 1 ?-) 

A shell burst about twenty-five meters away from a soldier, 
21, but he continued in the military service thereafter for one 
month, having only one sympton, a trembling of the arm. 
This persisting, he was evacuated to Calais, then to Dury to 
the hospital for the insane where he stayed six months. He 
was transferred from Dury to the Belgian Hospital for the 
Insane at Chateaugiron on August 20, 191 5. He remem- 
bered nothing of his stay at Dury, Calais, or of anything 
that happened after the shell-shock. He had no complaint 
and wanted to go back to the front. He was well oriented 
for time and space and had no disorders of association or 
perception. Besides the persistent, retrograde amnesia, he 
showed certain neurological disorders, occasional slight ver- 
tigo, a generalized tremor especially affecting the arms but 
disappearing almost completely at rest, lively tendon re- 
flexes, intense dermographia and cardiac erethism. Diag- 
nosis was made of acute, convulsional psychosis with agita- 
tion, convalescent phase. 

During March he was quiet and worked about the hospital. 
In April the patient had a number of seizures of an hysterical 
nature. In June it was possible to evacuate him to full con- 
valescence. He went back to the front and stayed there, but 
shortly developed catatonic signs with visual hallucinations 
and delusions of persecution of a non-systematized nature, 
such as poisoning, being magnetized, etc. He was at this 
time poorly oriented for time, assumed bizarre and theatrical 
attitudes, showed Ganser's symptom, was oversuggestible 

I and agitated and sleepless. Diagnosis of dementia praecox 
was now clear. 
Hoven remarks that this case is important in that it sug- 



214 SCHIZOPHRENOSES 



Influence of war experience on the content of hal- 
lucinations and delusions. 



Case 157. (Gerver, 191 5.) 

In one of the divisional field hospitals Gerver examined a 
patient with a very vivid paranoic condition. The following 
were some of his hallucinations and delusions: 

The patient asserted that everyone considered him a spy. 
Voices continually told him: "You are a spy." "What? 
Spy? Caught? What? " "You will be shot by the Ger- 
mans for espionage." About three months before his present 
trouble, the patient had been wounded in left shoulder by a 
fragment of a large projectile. The wound healed and ex- 
amination showed a big scar with attachments to the bone. 
The patient asserted that now he could not touch anything 
with his left hand, as there immediately go from it "some 
currents " to the Germans in the trenches and they at once 
begin shooting at the Russian position. Later, the patient 
could not even look in the direction of the German front, 
for all he had to do was to throw a glance in that direction 
and the Germans would at once begin a bombardment. 

All these phenomena he explained as being due to the fact 
that the fragments of the large projectile which entered his 
shoulder were poisoned and charmed. Through these frag- 
ments there went currents from his hands to the Germans. 
The patient always supported his left hand with his right, 
in order not to touch anything with it. He slept only on his 
right side, so as not to touch the bed or floor with his left 
hand. During the examination and conversation the patient 
tried always to look downwards, so as not to throw a chance 
look in the direction of the German front and call out their 
fire. 



SCHIZOPHRENOSES 2 1 5 



An Iron Cross winner had a hysterical-looking 
attack (reminiscence of a bayoneted Gurkha). 
Later he begins to talk of " this damned war that is 
so vulgar" and of " atrocities, concrete and ab- 
stract " : Shortly the diagnosis, hebephrenia, had 
to be made. 



Case 158. (Bonhoeffer, 1915.) 

An Iron Cross winner, 21, in the field from August, 1914, 
to the middle of March, 1915, at first in France, later in 
Russia, finally went to hospital for rheumatism and sciatica. 
Three months later he had to be transferred to the Charite 
in a state of delirious excitement. 

The attack began suddenly. He thought he was in the 
field telephoning with his captain, trembled, threatened to 
injure people about him, said he could not hold the position 
with the few men he had, and the like. Next day he quieted 
down and became oriented for time and place. He explained 
that he had seen a Gurkha coming upon him with a mallet, 
by way of revenge upon him because he had stuck his bay- 
onet in the Gurkha's breast. Behind a little hill he had 
seen Frenchmen and Englishmen, from which he drew the 
conclusion there was going to be an attack that night. A 
little cloud of dust he thought was enemy cavalry. In point 
of fact, he said he had once on patrol stuck a Gurkha through 
and the Gurkha's eyes had since followed him in his mind. 
He had seen him crawling along the ground one evening and 
heard his step. The patient had imperfect insight into 
these hallucinations when questioned about them during the 
daytime, and still talked somewhat as if the experience was a 
real one. 

At first the situation seemed probably one of hysterical 
delusion, for which the Gurkha experience served as material. 
In point of fact, further observation in the clinic showed that 
the diagnosis of hysteria was wrong. He was induced to 
write out his experience in a style quite like his conversation ; 
and there was a queer tendency in his writing to the use of 



2l6 SCHIZOPHRENOSES 

foreign words, somewhat improperly used. After a time he 
began to sit about dully and at times to run about and 
throw himself into and out of bed, or strike rhythmically 
with his shoes on the floor, or draw his shoulders together, 
making grimaces, rolling his eyes and breathing deeply. He 
said he had to make these movements involuntarily if he 
were in some way excited. But the peculiar conduct also 
often occurred without any emotional prod. His emotions 
were variable, but on the whole indifferent and not always 
quite suitable. 

He frequently said he wanted to get into the field again, 
giving vent to superficial phrases, such as "atrocities, con- 
crete and abstract," and "this damned war that is so vulgar." 
Yet a few minutes later he would say he wanted to go to war 
at Amsterdam as Amsterdam had pleased him very much. 
He said he now had a good many thoughts and ideas which 
formerly he had not had. He had not been promoted, he 
said, because he had once angered an officer in another com- 
pany. 

His field hospital history told of certain oddities, such as 
his lying stiffly in bed heedless of what was going on about 
him, falling into causeless depression, failing to sleep, and 
wandering about. 

As to previous life, only his own data were available. 
He had been a moderate scholar, had been rather irritable 
and thought a peculiar character. In the ward, he showed 
baseless antipathy to certain patients and said they were 
well. He seemed to have no insight into his condition, 
yet wrote in a letter that the insane state in which he was 
had very much " augmented his mental organism." The 
diagnosis of early hebephrenic disorder could now be con- 
sidered established. 



SCHIZOPHRENOSES 2 1 7 



Occipital trauma. Mystical visual hallucinations 
and explanatory delusions. 



Case 159. (Claude, Lhermitte, Vigouroux, 191 7.) 

A soldier, 33, single, was wounded in the right occipital 
region by a shell burst September 25, 191 5. There was no 
sign of focal lesion, but a trephining operation was done, 
which healed perfectly. No disturbance of vision ensued. 
The soldier was sent to convalesce two months after having 
been examined by P. Marie at the Salpetriere. He went 
back to his regimental station and was put into the auxiliary 
service April 26, 191 6. 

In the early days of September, that is to say, a year after 
his injury, he had a vision. Above the church cross at 
Chantenay, where he then was, he saw a rainbow-colored 
bird, passing slowly in the sky. He lowered his eyes and the 
apparition followed and was projected on the white walls 
around him. After some time it disappeared. The soldier 
himself wondered whether his brain injury might not have 
something to do with the vision, but none of his comrades 
wounded in the head had had any such vision. So then he 
thought of tobacco, of which he was a moderate user, and 
stopped smoking, but the vision returned in the same in- 
tensity four months later. On examining the bird's face 
carefully, he found that it was the Holy Virgin's. In dreams 
he also had analogous visions and in the dreams the Holy 
Virgin spoke to him, but what she said he did not 
remember. The bird's head did not speak to him. The 
soldier was now convinced that it really was the Holy Virgin 
who had visited him in the form of a bird. He remembered 
that he had asked Notre Dame de Lourdes to protect him on 
the day when he was injured. He had, in fact, eaten a bit 
of cheese that day upon which he had inscribed a prayer to 
the Holy Virgin. 

Sometimes he saw a red globe shining like a church lamp; 
sometimes white or black ladies descending from the sky; 
sometimes other visions. Now the Holy Virgin was to direct 



218 SCHIZOPHRENOSES 

all the soldier's life, but why should he be specially favored? 
Was he not to be called sooner or later to hold a high rank? 
He confessed, in fact, that he was to be the King of France, 
and, like Joan of Arc, was to save his country. Now the 
soldier began to understand the hidden significance of his 
surroundings. Everything around him was symbolic, thus, 
white, of purity, order and royalty; red, of anarchy, disorder 
and atheism. Some white ship which he saw outstripping 
some darker ship showed him how the kingdom of France 
was arriving once more. In fact, there was a symbolism in 
the whites and yolks of eggs, and the proportion of yolk to 
white was as one to five. He made talismans to exorcise 
bad spirits. 

Were there auditory hallucinations? If so, they were only 
episodic and took no part in either the construction or the 
fixation of the man's delusional system. Thus, a voice once 

said to him, " All is not lost. You will be ." May 25, 

191 7, he entered the neurological center at Bourges. 

As to the interpretation of this case, it seems that the 
patient's mother had crises of depression which at one time 
caused her to be interned in the Charite. The contributors 
of this case do not believe that there can be any causal link 
set up between the mystical delusions and the brain injury. 

As an auxiliary the soldier has a right to twenty per cent 
compensation for his head wound with loss of substance 
without bulging of the dura mater. Of course, as an insane 
person he must be retired. The aggravating or accelerating 
part played by fatigue, emotion and cranial trauma must, 
from the standpoint of compensation, be taken into account. 



SCHIZOPHRENOSES 219 

Shell-shock dementia praecox. 



Case 160. (Weygandt, 191 5.) 

A subaltern who had been in the service since 1909 was on 
patrol under shell fire from the enemy, but shortly thereafter 
came with his detachment into the zone of the German fire. 
Six men, two steps away from him, were killed by a shell. 
The officer remained stationary with the rest of his detach- 
ment until darkness set in, then returned, made his report 
in due order, but thereafter tremors set in over his whole 
body and he lost consciousness. He was carried to the 
hospital and on the way met his best friend whom he did not 
recognize. Arrived at the hospital he was unable to give 
answers to questions or obey requests for two or three hours. 
He thought he was hearing calls, commands and a dull 
drohnen. If an automobile passed he was frightened and 
cried, " Auto! Auto!" He remained subject to inhibition, 
anxiety and insomnia for a long time; pulse accelerated; 
visual fields somewhat contracted for red. Face asymmetri- 
cally innervated and dermatographia. Sent to the reserve 
hospital, he was still apprehensive, especially at night, but in 
the course of a few days became perfectly tranquil. Only 
if he took part in the singing of war songs did he feel transient 
sensations in his knees. 

Here is a case of psychic shock with many traits, such as 
inhibition and hallucinations, suggestive of dementia praecox. 
The Abderhalden reactions (cortex, white matter, testes, 
not thyroid) all, according to Weygandt, are suggestive also 
of dementia praecox. 



220 SCHIZOPHRENOSES 



Shell-shock dementia praecox. 



Case x6i. (Dupuoy, 191 6.) 

A machine gunner, 23, was the sole survivor, March 18, 
1915* of the explosion of a large calibre shell in a block house 
containing ten men. He worked himself out of the debris 
and came to Dupuoy's attention in September, when an ex- 
tension of leave was asked for him. 

There were two groups of symptoms; persistent head- 
ache, painful hyperacousia, vertigo, tremulous walk, cervical 
spinal column stiff and painful both spontaneously and to 
pressure, muscular weakness, tremor of hands, hypesthesia 
of extremities especially upper, exaggeration of tendon and 
bone reflexes with tendency to ankle clonus and patellar 
clonus, sterno sign lively, frequent nosebleeds (two to four 
times a week) , profound sweating, unequal pupils. 

On the mental side it was clear that the man's character had 
changed, according to information supplied by the mother. 
Aprosexia, impairment of memory, recollective and reten- 
tive, inability to give age, birth date and similar data. Words 
came with difficulty. Some disorder of comprehension; 
stereotyped replies; negativism; indifference; he would sit 
hours in a chair or on a bed silent and inactive. Fixed 
attitudes; dull glance; eyelids half closed. In short, it 
seemed as if this patient was a case of catatonic dementia 
praecox. 

Re dementia praecox and shell-shock, Stansfield remarks 
upon the similarity of certain symptoms found in Shell- 
shock to those of dementia praecox; for example, apathy, 
retardation, amnesia and speech defect. According to Stans- 
field, one often gets the impression in a Shell-shock case as 
though the trench and shell fire stress had merely brought 
out a latent dementia praecox. 

Re his new ' 'sterno" sign (sternomastoid contraction on 
percussion of neck at level of third dorsal vertebra), Dupouy 
claims it negative in normal subjects, positive in concussion, 
meningitis, and general paresis. 



SCHIZOPHRENOSES 22 1 



Shell-shock ; fatigue ; fugue ; delusions. Recovery. 



Case 162. (Rouge, 1915.) 

A sergeant, 40, had had nineteen years of service and had 
been married five months when he was recalled to the colors 
when war broke out, and sent to the front. March, 191 5, 
he was exposed to bomb explosions during a very intense 
bombardment. He then got into the way of saying that he 
was akin to everybody. April 20, he was evacuated on the 
score of general fatigue, rejoined the company May 17, left 
his comrades at the end of June, and was taken up as a 
deserter by the police, who, observing his state, brought him 
to a hospital. He there showed " cerebral overexcitement " 
with " incoherence and nervousness.' ' In two or three days 
he was much better. He was evacuated on the sixth day to 
the hospital at Vichy. 

There was amnesia for the fugue and he could remember no 
further back than the extraction of a tooth at the Vichy 
hospital. In fact, he attributed the fugue to this dental 
operation. His wife took him home, but he soon threatened 
her with a revolver ; got better in the night and next day went 
about apparently normal, buying things, however, extrava- 
gantly. His delusional state began once more, and two days 
later he was brought to Limoux. It seems that, while in 
Mauretania, he had formerly shown signs of mental disorder, 
having a mania for wireless and airplane inventions and the 
like. A cousin-german had also been in a hospital for the 
insane twice, recovering each time. There was a lingual and 
manual tremor. The man had not been recently alcoholic. 
He was a little irritable and showed a little megalomania, 
but worked hard and made himself useful. He went out, 
recovered, November 12, 191 5. 

Analysis indicated that this sergeant received a moral 
shock as a consequence of his fatigue and the shell fire, which 
emerged in a spell of confusion. It may be that his pre- 
disposition had something to do also with this spell and the 
fatigue. In any event, it seems as if the latter phenomena 
were not all assignable to war stress. 



IX. CYCLOTHYMOSES 
(THE MANIC-DEPRESSIVE GROUP) 



A maniacal volunteer. 



Case 163. (Boucherot, 191 5-6.) 

An Alsatian became the object of much attention when he 
enlisted at the outbreak of the war in the infantry at the age 
of 59. He was interviewed and soon became more than 
naturally exuberant. The peculiar things he did soon brought 
him to Fleury in a gay and expansive mood, singing and 
talking as hail fellow with everyone he met. 

The next day he grew more excited, disrobed and threw his 
things out of the window, filled his bed with excrement and 
wanted to smear the orderly therewith. He took other 
attendants for old friends and wanted to kiss them. His 
language and ideas were incoherent. He broke glass. 

This situation of alternate joy and anger lasted one month, 
leaving him in an excitable, unruly state. He wrote many 
prolix letters to the prefects and the ministers, insisting on 
the discharge of certain patients and offering plans for the 
defense of France. He got better and finally, in October, 
1 9 14, was invalided home still slightly exalted. 

Re the cyclothymias, Montembault remarks that manias 
have been less numerous than melancholias in the present 
war, whereas in 1870, manias were more common than mel- 
ancholias. Morselli likewise remarks upon the rarity of 
manias amongst the Italian soldiers. Butenko reports upon 
the maniacal cases amongst the Russians and how the men 
wish to enter the ranks, the women the nurse corps. E. 
Meyer, for Germany, found 4 per cent manic-depressives. 
Birnbaum quotes from Bonhoeffer (3 per cent) and Hahn 
(2 per cent) for war times as against Stier's 9.5 per cent of 
cyclothymic cases in the antebellum period, 1905-1906 

222 



CYCLOTHYMOSES 223 

Fugue: melancholia. 



Case 164. (Logre, 1916.) 

Logre classifies as a melancholic fugue the adventures of a 
man who had been depressed for some days, had stopped 
talking and eating, and ran away suddenly in the middle of 
an attack of anxious agitation. He was very anxious over 
the health of his daughter, whom he thought to be severely 
ill. It was, in fact, to go to Paimpol that he deserted, but he 
deserted with his arms and without any money. He went off 
on foot "in the Brittany direction." He had gone 50 kilo- 
meters, the next day, and was picked up near Chateau- 
Thierry by two gendarmes, who fell upon him, seeing his 
regalia, and cried, "Give yourself up! " He replied in a firm 
voice, "No, I shall not give myself up!" and seizing his gun 
he made at one of the gendarmes. There was a fight. The 
gendarme declared in his report that he judged it opportune 
to retreat behind a tree. The soldier, knowing his trench 
lore very well, barricaded himself behind a pile of beets. 
There he would have held the gendarmes in check for some 
time if another had not succeeded by a detour through some 
woods, in catching him. He gave himself up after firing 
several ineffective shots, but not without getting a bullet in 
his left thigh himself. With the charge of desertion and 
attempt to murder, he was handed over for mental exam- 
ination. He was, in fact, a melancholic patient, subject to 
attacks of anxiety, and requiring long observation at a 
neuropsychiatric center for diagnosis. 

Chavigny observed numerous victims of melancholia char- 
acterized by war terror. He remarks a somewhat curious 
fact that, whereas the melancholies were numerous and their 
mental states related to the war, on the other hand, the 
paretics were rather apt to be maniacal than melancholic. 
Soukhanoff, however, remarks on the occurrence of depres- 
sion in a great number of types of psychosis, as was found 
in the Russo-Japanese war. Soukhanoff found frequent in- 
stances of schizophrenia, wherein the melancholia tends to 
conceal the actual dementia praecox. Soukhanoff predicted 
that depression will figure largely in the war. 



224 CYCLOTHYMOSES 

Apples in No-Man's-Land. 



Case 165. (Weygandt, 1915O 

A soldier in November, 19 14, suddenly climbed out of the 
trench and began to pick apples from an apple-tree between 
the firing lines. The idea was to get a bag of apples for his 
comrades, but he began to pelt the French trenches with 
apples. He was called back and on account of his strange 
conduct sent to hospital. Here he was at times given to 
pressure of speech and restlessness ; he would climb the posts 
of the sleeping room and then loudly declare he wanted to 
get back to the trenches ; he did not want to go back to Ger- 
many alive; did not want to live over to-morrow; was guilty 
of a sin; had a spot of sin, Schand, on his heart. Sometimes 
he refused food and said anything else tasted better. It 
seemed he had formerly talked about the Iron Cross. 

After being transported to Germany, he was at first a 
little negativistic and apparently blocked. He talked about 
his experiences and said he wanted to go to Russia. He ex- 
plained the episode of the apples on the basis that they were 
all really hungry and that he had sought to encourage his 
comrades who were unused to war. He had noticed the 
French all shot too high. 

Physically there was a somewhat uneven innervation of 
the face, unilateral epicanthus and an areflexia of pharynx. 
Now and then the man was very irritable, but in general he 
was in an elevated frame of mind. 

Weygandt interprets this case as one of hypomania, re- 
marking that war influences may serve to bring out preex- 
isting manic depressive tendencies. 

Re differential development of mania and depression, see 
remarks under Cases 163 (Boucherot) and 164 (Logre). 



CYCLOTHYMOSES 225 



Four months in trenches : Depression ; war hallu- 
cinations, arteriosclerosis (aged 38). 



Case 166. (Gerver, 1915O 

A Russian reservist, a private, 38, went into the trenches, 
March, 191 5. Without taking part in any battles or sus- 
taining any injury, he four months later became depressed 
and had to be evacuated to a hospital and thence to the 
interior, little changed for the better. 

He was an ill-nourished man, of middle height, with pallid 
skin and membranes; arteries sclerotic; face, eyelids, and 
tongue finely tremulous; hands tremulous; slight dermato- 
graphia; exaggerated tendon reflexes; pulse 100. 

He seemed disoriented for time and place; looked weary; 
walked with back bent over; spoke in whispers, and ap- 
peared somewhat unclear. Thinking was slow and difficult. 

He occasionally shuddered and looked to one side, said he 
was afraid, and was constantly troubled by thoughts of fire. 
The Germans were pursuing him; he could hear their voices 
and footsteps. He himself was doomed, and his family also; 
he felt he was the cause of all the domestic woe. His own 
heart was dying away; he had fits of anguish and causeless 
fear, and was under the constant expectation of death. 

One day, he escaped from the hospital and went to the 
chief physician's tent, where he lay on the ground. When 
he was found and asked why he was there, he begged the 
physician to save him from the Germans. The man was not 
alcoholic and had no previous history of mental disease. 

Re early arteriosclerosis, Maitland in the second interim 
report of the British Association Committee on Fatigue in 
Warfare, speaks of the many Serbians, who, after six years 
of nearly continuous Balkan war, show a marked arterio- 
sclerosis. Maitland remarks that the line officers were al- 
ready showing (19 1 6) a growing delicacy of perception as 
to the "breaking point." Men that do not break may 
return from the lines, pale, with low blood pressure, and a 
faiblesse irritable, shown by restlessness of hands and feet. 



226 CYCLOTHYMOSES 



War stress : Manic-depressive psychosis. 



Case 167. (Dumesnil, 191 5-6.) 

A naval officer, 22, transferred from sea service, went into 
Belgium, November, 1914, in a Fusilleur brigade of marines 
and there greatly distinguished himself, growing very weary 
and enervated, however, about the middle of April, 191 5. 
His attitude to the men altered : he sometimes struck them ; 
gently, though, according to his account. They must do 
in ten seconds what they really could not do under ten 
minutes. The officer, in fact, had lost all notion of time. 
He went about agitatedly, contradicted his superior officers 
and was troubled because, as he said, they often were men of 
inexperience as compared to himself. He grew irritated, too, 
because there were Free Masons in the army and when he 
was sent to the asylum in July, 19 15, said it was the doing of 
the Free Masons. He did not seem to have any hallucina- 
tions. His ideas and sentiments were very labile, and a bit 
confused, and not all his interpretations dealt with Free 
Masons and occultism. August 5, however, the phase of 
calmness was again followed by agitation; he broke things 
and laughed explosively. August 10, another attack occurred, 
with destructiveness. During the next few days there were 
alternate phases of depression and excitation. He was nega- 
tivistic, resistive and struck attendants. 

Re war stress and psychoses, Morselli finds the acute cases 
on psychopathic soil. First in the list, he places the neu- 
rasthenias and psychasthenias, and second, the hysterias, 
two groups which, more than the remainder, may be said to 
constitute the so-called Shell-shock group. Third, he found 
depressions ranging over into a delusional state with suicidal 
ideas; fourth, a species of stupor, occasionally catatonic, 
recalling dementia praecox; fifth, transient hallucinatory 
states; sixth, confusions (Meynert's amentia?); last, manias. 

The above case of Dumesnil appears to be a pure case of 
manic-depressive psychosis developing on the war basis, but 
perhaps merely comes from a latent cyclothymia. 



CYCLOTHYMOSES 227 

Predisposition; war stress: Melancholia. 



Case 168. (Dumesnil, 1915-6.) 

A farmer, 30, was mobilized August 2, 1914, and was 
wounded in the hand September 27. He went back to his 
dep6t in December and stayed there until March, 191 5, when 
he was sent to Dunkirk. Before leaving the depot he said 
that he had heard soldiers declaring that he was not doing 
his duty, that he was going to be court-martialed, that life 
was at an end for him. At Dunkirk he said these same sol- 
diers continued to say the same things about him, forming 
a band about him, led off by a subaltern officer who meant 
to frighten him and to make him talk. One night sulphur 
was thrown at him for poisoning purposes; he complained of 
this to a sergeant and declared he did not understand why 
he should be thus pursued. After the bombardment of Dun- 
kirk the hallucinations grew more intense. He was sent to 
hospital and was so harried by the voices that he wanted to 
throw himself down a staircase but was caught in time. 
At the hospital for the insane he complained that his thoughts 
were being heard and loudly repeated ; he was made to make 
incoordinate movements ; was treated as a spy. He thought 
he must be a German or they would not treat him so. He 
waited for death as he wanted to be executed at once. 

This man's father was alcoholic. He himself at the age 
of fourteen had had a period of neurasthenia with some sort 
of nervous seizure for a period of five months. At 28 he had 
a rheumatic seizure which kept him in bed fifty days. A 
daughter born to his wife had died a few days after birth. 

Dumesnil' s analysis is melancholia with delusions of per- 
secution, due to war stress in a predisposed person. 

Re melancholia and the war stress, see remarks under 
Case 167. Re manic-depressive psychosis in the Russians, 
Khoroshko found 9.4 per cent of manic-depressive cases, 
the same percentage of epilepsies, 10 per cent of paretics, 
and 20.4 per cent of schizophrenic cases amongst a group of 
318 neuro-psychiatric cases. Almost all his manic-depressive 
cases had been patently so antebellum. 



228 CYCLOTHYMOSES 



Depression; low blood pressure. Pituitrin. 



Case 169. (Green, 1917.) 

A private, 22, was sent back from Germany as insane. He 
had been in the asylum at Giessen seven months, and a 
prisoner in all fifteen months. 

August 16, 19 1 6, he was admitted to Mott's wards at 
Maudsley in a markedly depressed and lethargic condition. 
He had improved somewhat in October, but still had periods 
of depression. He was put on thyroid extract (Green's 
treatment was in doses measuring from gr. \ to gr. 1, t.d.s. ; 
according to Green, the effect of thyroid extract is more 
rapid when coupled with pituitrin). In December he was 
given pituitrin extract gr. 2, t.d.s. In January, 191 7, he was 
no longer depressed or lethargic. He complained of pain in 
his back, found to be due to a bullet. This was removed. 

Re prisoners, Imboden found amongst 20,000 French sol- 
diers taken prisoner at Verdun after the severest drum fire 
and strain, only five neurotic cases (data of Morchen), and 
Wilmanns found but five neurotic cases amongst 80,000 
prisoners. Lust reviewed 20,000 war prisoners in Germany 
and found singularly few instances of neurosis. Shunkoff 
notes, however, that there are a number of psychotic cases 
amongst the prisoners because the mentally diseased who do 
not disturb the military routine are kept in the line. Bon- 
hoeffer found amongst Serbians taken prisoners by Germany, 
emaciation, atrophy, heart disease, and frequently tuber- 
culosis. (See Case 166.) Bonhoeffer noted the absence of 
psychoses amongst these Serbians, drawing the general con- 
clusion that campaign stress was unable to bring out psy- 
choses. But, although the exhaustion psychoses are not 
found, there are exhaustion neuroses or states of acute ner- 
vous exhaustion, characterized by somnolence and depres- 
sion, followed by a mild degree of overemotionality. vum 
Busch states that interned German civilians have gone into 
psychosis frequently. It is said that one in 10,000 war 
prisoners in Germany has committed suicide. Bishop Bury 
found at Ruhleben 60 or 70 cases of psychosis. 



X. PSYCHONEUROSES 



Hallucination in the field (surprise by BOCHES) ; 
scalp wound : Three psychopathic phases — (a) 
over-emotionality, (b) obsessions, (c) loss of feeling 
of reality (victim a " constitutional intimiste ")• 



Case 170. (Laignel-Lavastine and Courbon, July, 1917.) 

A cashier, 31 (of rather weak constitution but without 
hereditary or acquired mental taint — a religious man and 
for religious reasons chaste, always given to metaphysical 
speculation and introspection, but on the other hand, much 
interested in sports and very sympathetic with English 
manners), was about to go to live in the country on the ad- 
vice of his physician when the war broke out. He was 
called to the colors and shortly lost his tendency to bron- 
chitis, put on flesh, and felt delighted with his situation. 

After almost two years of effective service, June 2, 191 6, 
when his troop was cautiously advancing into a trench at the 
end of which they might be taken by surprise, suddenly the 
officer cried, " Sauve qui pent! The Bodies are on us!' 1 The 
patient remembered seeing Germans emerge from every side, 
remembered his fear, how he had turned about and crossed 
over a palisade, and then no more until he found a scalp 
wound being staunched by his comrades in the trench. He 
put on his own dressing and followed his comrades on foot. 

He quickly got well of his scalp-wound but remained in 
hospital, very weak, extremely impressionable, jumping at 
every noise. He got somewhat better with the rest in bed, 
though even a month after his hallucination, he had a spell 
of insomnia, thinking about his future and the possibility of 
a relapse, and having war dreams from which he would awake 
in a sweat. Once on awaking, he distinctly heard a voice 
saying, "Well, Charles? 11 This hallucination occurred five 
times, under exactly the same circumstances, except that once 
it was in the daylight. Adrenalin was given, 1 : 1000, 10 

229 



23O PSYCHONEUROSES 

drops the first day, 20 the second, 30 the third, and a like 
amount on the following days. After three days of such 
treatment, the patient said he felt much better. Later he 
had a period in which he had lost self-control and could no 
longer take any initiative. Thus, if he wanted to reply to 
his mother, it seemed to him that some one not himself was 
ordering him to write. He now asked himself if he were not 
really dreaming. He would not be sure of his actual exist- 
ence unless something happened to prove it, such as the 
nurse's bringing him a plate. 

In short as the first phase of diffuse over-emotionality had 
been succeeded by a second of obsessions, so the obsessive 
phase was succeeded by a third phase of mild loss of the 
feeling of reality. The first phase following the wound was 
one of disorder of attention, of memory, and in fact of all the 
mental functions, associated with tremors, tachycardia and 
dizziness. The second phase seemed, as it were, to crystal- 
lize intellectually the anxious apprehensiveness of the first 
phase. There were fears that the ceiling would fall; there 
were scruples concerning the past; there were fearful pre- 
monitions for the future (such as, that any bomb he might 
pick up would burst). According to Laignel-Lavastine and 
Courbon, there may have been a predisposition in the vegeta- 
tive system of this subject, or even a basis in his tuberculosis, 
of which, in fact, the X-ray showed still some slight evidences. 
The obsessions appeared at night, at a time, namely, when the 
vital rhythm is passing from a sympathotonic period over 
into a vagotonic period, at a time when the organic sensations 
are apt to swim to the fore. According to this analysis, 
these somatic sensations, precisely those that the battle- 
field had also brought out, brought out again the other emo- 
tions which he had felt on service. It was always the emo- 
tions first developed in military service that were revived in 
the disease. In the third phase, the physical condition of the 
patient had grown much better pari passu with disappear- 
ance of the obsessions and the onset of the personality dis- 
order. The adrenalin raised arterial tension, and going down 
to the sympathetic caused the anxiety and war emotions 
linked therewith to disappear; but the adrenalin treatment, 



PSYCHONEUROSES 2T, I 

according to Laignel-Lavastine and Courbon, disturbed the - 
organic sensations so suddenly that there was a break between 
the new conscious status and the old. In consequence, 
the patient felt that these new sensations no longer really 
belonged to him but were of a xenic character, imposed upon 
him from without in such wise that he continually asked 
himself whether he was really dreaming or no. This man 
was a constitutional intimiste; a psychasthenic en herbe. 

Re neurasthenia, Lepine notes that there are transient 
and relatively permanent cases. The term is often used to 
cover graver disorders, such as various melancholias and 
anxieties. As a rule, in France, the neurasthenics are evacu- 
ated for fatigue. There have been a number of cases in 
officers, who find themselves unable to make decisions on 
the minute and to remember military facts, or perhaps are 
unable to make any physical or intelligent effort whatever. 
A true neurasthenic, however, ought not to be a confused 
person. He is a man with a rather unusual clarity of view 
as to his situation; and his trouble appears to him to be 
somatic rather than as of the nature of a depression. He 
feels that, if he could only rest, he could be cured. Neuras- 
thenia, according to Lepine's war experience, is practically 
always the disease of a highly cultivated nervous system, 
and appears in men who have undertaken responsibilities. 
There is a group of young men who have never been physi- 
cally strong, bowled over at last by some small event, such 
as a diarrhoea, and unable to carry on. Such men, perhaps, 
are likely to have some traces of an old tuberculosis, an 
adrenal insufficiency, or insufficient hepatic function. Marti- 
net has found them hypotensive and rather poorly aerated. 
There is another group of neurasthenics (Maurice of Fleury) 
that are old arthritics, with increased tension. These cases 
are not found at the front because conditions there rather 
tend to reduce the trouble; but they are found doing office 
work in the interior. Besides these cases of the " cultivated" 
group, Lepine also finds a number of neurasthenics amongst 
the peasants, in whom anxious ideas may lead to hypo- 
chondria. 



232 PSYCHONEUROSES 



Fugue, hysterical. 




Case 171. (Milian, May, 1915.) 

The fugue of an adjutant who left his regimental relief 
post at Palameix Farm and was found several days later with 
his family at Castelsarrasin, was reconstructed from partial 
records as follows: 

November 27, 19 14, after a night in the trenches, when 
two shells burst near him, the adjutant turned up at the 
relief post with wild eyes and a complaint of fatigue, and of 
an old wound and headaches. The wound he had gotten in 
a fight which gained him his grade of adjutant. The physi- 
cian prescribed rest. He sat down by the stove, silent and 
dejected, and at about four o'clock, in the presence of the 
medical assistant, made preparations to go, leaving sack and 
saber behind, but taking outer garments and revolver case. 
On the way from the farm, he met comrades and told them he 
had been evacuated to his depot on the colonel's order, and 
walked with them, Indian file, in the midst of falling shells, 
the others talking but the adjutant himself silent. At night- 
fall, he said, " Good evening," and parted from them. Of 
his further course to his home, all recollection was lost by 
the adjutant; in fact, he did not remember anything beyond 
the Palameix Farm, where he had seen a comrade wounded 
in the head. He got home November 29th, at eight in the 
morning. He had most of his money with him, having 
traveled by train some distance without a ticket; moreover, 
without asking for a ticket, and without having eaten. When 
the ticketman in his home town asked him whether he was 
back from the war, he looked at him vaguely and went out 
without replying; nor did he reply to a newspaper man on 
the road home. This was the more strange as he was ordi- 
narily an affable person. 

He had a convulsive crisis at home, after which he was 
exhausted and apparently unable to move or reply. A physi- 
cian said that he had had a cerebral shock. When the police 
arrived, two hours later, he was apparently delirious, saying 



PSYCHONEUROSES 233 

such things as, " The Christians want to shoot me but I know 1 
the rules! Come, boys, stay in the trenches! " "There are two 
more dead ones! " etc. During the day he recovered con- 
sciousness and was greatly disturbed at his military crime. 

In point of fact, he had had, at the age of 17, analogous 
crises, as was certified by Regis, who had cared for him from 
1907 to 1909 for hysteria with sudden somnambulistic at- 
tacks and amnesia. 

While in prison after his arrest, he also had hysterical 
crises with agitation, flushed face, hard attempts to vomit, 
respiratory disorder due to interference in the throat (globus 
hystericus), and delirious phenomena (" Germans had fol- 
lowed him home"). 

After his birth his mother had had two miscarriages 
and a stillborn child. The adjutant was declared irrespon- 
sible and acquitted. This is apparently an instance of 
hysteria without stigmata. 



234 PSYCHONEUROSES 

Hysterical Adventist. 



Case 172. (De la Motte, August, 1915) 

An engineer, 31, in the Landwehr at the outset of the 
campaign, was first put on sentry service in Berlin on the 
ground that he was an Adventist. He was later put into the 
military service and had difficulty because he did not want 
to serve on Sunday. He was shoved from one company to 
another. He refused to be inoculated and was arrested 
therefor. In the prison, he began to hear God's voice calling 
to him distinctly to tell his fellow-men that the end of this was 
going to be the end of all things. Back in the barracks, he 
again heard a voice — " Come forth! " — "Go I" He went! 
He had his revelations then published in the form of tracts, 
and held Bible readings day and night among his friends in 
Bremen — looking for the signs of the times in the Bible 
sayings. One of his fellow Adventists finally warned the 
police, and the military authorities put him under psychiatric 
observation. He proved to have numerous stigmata of 
hysteria. He talked freely about his visions, and was aware 
that he was punishable. 

Here, then, was a case of hysterical psychosis, liberated by 
military service. 



PSYCHONEUROSES 235 

Fugue, psychoneurotic. 



Case 173. (Logre.) 

The question, Is this escape really a fugue? is brought up 
not only in epileptic, alcoholic, and melancholic cases, but 
also in cases suggestive of psychoneurosis. A son of an in- 
sane person was subject to what may be called a phobic or 
obsessive fugue. The case may be called one of morbid 
cowardice and was observed in a soldier in the trenches. In 
point of fact, the man had always been an anxious and fear- 
some person, given to phobias. He had night terrors and 
fear of diseases and death. He was agoraphobic in adoles- 
cence, and had to have a policeman or passerby go with him 
through a public place. He had had also suicidal and homi- 
cidal obsessions, and periods of psychoneurotic anxiety. 

This man's sojourn at the front put his morbid personality 
to a cruel test. He was soon known by all in the trenches as 
a froussard. He had a terrible fear of the guns, jumped, 
grew pale, trembled, complained of palpitations, lumps in 
the throat, etc. He was the laughing-stock of his comrades; 
but according to the patient himself, he was more afraid of 
his own emotion than of the shells, although his comrades 
couldn't understand it. He was employed as a kitchenman, 
in a post not much exposed. A more resolute comrade 
helped him to escape, escaping also himself, thus bringing up 
the problem of fugue a deux. Limited responsibility was 
decided for the case, although the fugue had been aided by his 
morbid anxiety. Of course, his place was not in the trenches 
at all. He was condemned to two years in prison. After 
his sentence, he was given a chance to rehabilitate himself by 
sending him again to the trenches, but he had to be evacuated 
a few weeks later on account of his increasing emotionality. 



236 PSYCHONEUROSES 



Shell-shy; war bride pregnant: Fugue with am- 
nesia and mutism. 



Case 174. (Myers, January, 1916.) 

A rifleman, 30 years old, was brought to a casualty clearing 
station, looking like an imbecile, with a history of having 
wandered about aimlessly, not knowing where he was or what 
he was doing. On questioning, he remained absolutely 
speechless and terrified. Four days later, in conversation 
with Major Myers, he was got to speak in a faint voice about 
his wife, home, and occupation, saying that the month was 
October (when it was actually August) and that he had been 
in France two months, when it was actually twelve. He 
described emotionally certain trench scenes, and then thought 
of his wife sewing 

Hypnotized, he remembered going into a dug-out after 
running away from shells ; he was made to talk in a loud voice. 
Next day, during hypnosis, proper orientation for time re- 
appeared. He was got to write an ordinary soldier's letter 
to his wife. The following day he was active, making beds, 
but was mute (there was a case of mutism in the same ward) . 
Under hypnosis speech returned. He had gone to a horse 
show, and upon his return, something hit his back ; shells had 
begun to fall. Found hiding in a shack, he was carried to a 
hospital in an ambulance. After this hypnotic treatment, 
the power of speech was maintained, although his voice be- 
came faint or failed whenever he was asked about the incidents 
described above. Next day he waked speaking normally, 
nudging his neighbor and asking, "Is it me that's talking?" 
He had before appeared dull and depressed, but now appeared 
an intelligent, agreeable, and garrulous fellow. It appears 
that his wife was a war bride and he had heard some months 
since that she was pregnant. He had been troubled, thinking 
she was in money difficulties and kept thinking about a 
friend whose wife had lost her first baby. Recovery appears 
to be complete except for occasional headaches, and the 
patient is now serving in his reserve battalion. 



PSYCHONEUROSES 237 

A neurasthenic volunteer. 



Case 175. (E. Smith, June, 1916.) 

A man who volunteered for service at the outbreak of the 
war (he had recently been an inmate of a sanatorium) was 
sent back to England as neurasthenic after three trying 
months at the front. The case sheet read that he was subject 
to dazed conditions. In hospital he suffered from insomnia, 
and before his slight periods of sleep he constantly had visions 
of two comrades who had been terribly lacerated at his side. 
These hallucinations in their reality aroused in him a fear 
that he was insane. 

There were also terrifying dreams, beginning with episodes 
at the front and ending with sex experiences. These dreams 
were ended by seminal emissions. These formed a second 
cause for the patient's belief that he was insane, as he said he 
remembered literature read as a boy concerning spermator- 
rhoea. 

In the treatment of this case the writings of psychologists 
who had studied hypnagogic experiences were used and the 
absence of hallucinations during waking hours was stressed. 
The remembered literature regarding spermatorrhoea was 
discounted by the rational explanation of his state. 

He seemed to be getting on well when a trivial accident 
caused a relapse. While he was saying goodby to his wife, 
who had visited him, she was taken ill, and he went home 
with her. He was punished for being late in returning to the 
hospital. Although no moral stigma attaches to confine- 
ments in barracks in most soldiers' minds, in this man a 
depression was produced and suicidal talk followed. It 
seems that his father had been sent to jail when he was a child, 
and he felt he had been tainted by his father in such wise that 
his * ' criming " was due to heredity. With the removal of 
this misconception he became more rational and immensely 
improved. 



238 PSYCHONEUROSES 



Five months* war experience: Neurasthenia in 
subject without heredity or soil. 



Case 176. (Jolly, January, 191 6.) 

A 38-year old soldier is Jolly's example of a neurasthenia 
produced in a person without previous neurasthenic traits or 
hereditary factors. This soldier had been a moderately good 
student and never ill. He went into the battle line in De- 
cember, 1 914, and came out in May, 1915, on account of ex- 
haustion. The case is not wholly convincing since the 
patient had a shrapnel injury of the skull, described as of so 
inconsiderable a degree that he was not put on the sick list 
on its account. The patient finally arrived at the Nuremberg 
Hospital, complaining of pressure in the head, as if there was 
a band around the head, and dizziness. He wept a good deal 
saying that the sight of the dead had frightened him. Sleep 
was restless and there were unpleasant dreams of the battle 
field. Intelligence was not in any degree disturbed. The 
supra-orbital points were sensitive to pressure. The tongue 
showed a marked tremor and was coated; the mechanical 
excitability of the muscles was increased; and there was 
reddening of the skin on stroking. There was a fine tremor 
of the extended fingers, less tremor of the head and of the 
body at large. Knee-jerks normal. Nutrition well pre- 
served. Partial recovery in the hospital. 



PSYCHONEUROSES 



239 



Importance of arterial hypotension in the diagnosis 
of psychasthenia. 



Case 177. (Crouzon, March, 1915.) 

A man of 32 (never well, with general weakness, ideas of 
consumption and vacuous thinking following a good recovery 
from bronchitis at 28, unsuccessful in business, subject to 
weaknesses) had had eighteen months antebellum of what 
might be called psychasthenia. There were spells of loss of 
consciousness without convulsions, and probably of hysterical 
nature. There had been for two years insomnia^and a general 
hypobulic slowing down of work. 

In military service the crises became more frequent, 
coming two or three times a week. Tuberculosis could not 
be shown, nor was there any organic lesion of the nervous 
system. The arterial tension (Potain sphygmomanometer) 
stood at 11. 

According to Crouzon, arterial hypotension is an objective 
sign tending to assure the organic nature of a psychasthenia. 
Whereas simple neurasthenics are hypertensive, others have 
long been recognized as hypotensive ; but heart experts have 
recognized this asthenic hypotension more than psychiatrists 
or neurologists. In differential diagnosis it is necessary to 
consider and exclude the early hypotensions of pulmonary 
tuberculosis and those of Addison's disease. This hypo- 
tension is most frequently observed in constitutional neuras- 
thenics and psychasthenics. Hypertensive drugs, adrenalin, 
tincture of colchicum, have produced a transitory improve- 
ment in a number of cases, but the amelioration has halted 
with the stoppage of the drugs. 

Re hypotensive and hypertensive cases, see remarks of 
Lepine under Case 176. See also Case 169, illustrating some 
contentions of Green, from Mott's clinic. 



24O PSYCHONEUROSES 



Service in France and Salonica : Psychasthenia. 



Case 178. (Eder, March, 1916.) 

A man, 29, after some months' service (three months in 
France and later in Salonica) was invalided for backache, 
insomnia, and enuresis. It seems that this married man had 
never done any work after leaving school at 18, having sub- 
stantial private means. He had been married for 2>h years, 
had a son, and was, according to Eder, perhaps morbidly 
attached to his wife and child. He had been a sportsman 
and was selected for sniping work in France. The son of a 
shipbuilder, he had always planned all kinds of ships and 
engines, never to be used. After seeing the world, he was 
about to enter his father's business when he had to take care 
of his father in a nervous breakdown. After a second attack, 
the man never entered business. 

February 6, 191 6, wide-spread patchy analgesia and lumbar 
hyperesthesia were found. He thought sluggishly, being 
restless and holding attention poorly. He began twenty 
letters, destroying each after finishing a few lines. He was 
shy and felt that everybody was looking at him. He became 
speechless if he had to address his commanding officer. 
He had an obsession to mark each flagstone and touch 
each post, and various counting and arranging obsessions. 

The Horme (Jung) was elusive. A dream: "I was in a 
cargo boat in the river; we were steering straight into ferry 
and harbor. The pilot rang down 'Full speed to stern'; I 
pushed him out of the way, and rang down ' Full speed ahead, 
two points to starboard.' We went straight past ferry and 
harbor without accident." Again, a few days later, "In a 
motor car, came to some rocks which sprang up in front of 
me. The machine broke down. I abandoned it and clam- 
bered over the rocks. It was tough work. My object was 
a ship. I got to the ship, took hold of the wrench, and 
fignalled 'Let go.' " Herein, according to Eder, are certain 
obvious symbolic conversions. 



PSYCHONEUROSES 24 1 



Antebellum attacks, with dizziness: Fainting on 
horseback. Neurasthenia. 



Case 179. (Binswanger, July, 1915O 

A harness-maker, 37, a corporal, was called to the colors 
on the second day of mobilization. He was attacked by a 
slight dizziness in the evening (see previous history below). 
He went into the field on August 7 and had repeated attacks 
of dizziness, despite which he took part in several skirmishes. 
He could not ride on horseback, since dizziness, ringing in the 
ears, headaches, and trembling of the whole body would 
develop. October 27 a severe fainting attack came while he 
was sitting on a horse. He woke ten hours later, vomited 
several times and felt dazed. Two weeks later hearing in 
the right ear began to be impaired. During several transfers 
from hospital to hospital near the East front, there were two 
more severe attacks of dizziness and vomiting. Brought 
back to Germany, the patient finally came to the Jena 
Hospital, May 20. 

The estimate of this case depends somewhat on the previous 
history. He appears to have come from a healthy family, 
was married, and had two healthy children. His bodily and 
mental development had been normal; he had been an un- 
usually good scholar, but he stammered from his tenth year 
without apparent reason. He had had treatment in an 
institution for stammerers at 17, achieving a complete cure 
in six weeks. His military service was as a cavalryman, 
1 897-1 900, after which he had married. There was no excess 
in alcohol; he was not a smoker. From his own account, he 
had always been somewhat nervous, had trembled easily, 
and had fallen to stammering when excited. In 19 13 there 
had occurred, after physical exertion, three violent attacks of 
fainting, with dizziness, vomiting, and excessive perspiration, 
each attack lasting from two to three hours. However, from 
that time to just before the war, he had been free from attacks. 

On examination at the Jena Hospital, the patient com- 
plained of general weariness, a feeling of pressure in the back 



242 PSYCHONEUROSES 

of his head, a hammering all over the head, ringing in the 
right ear, impairment of hearing in this ear, a feeling of 
dizziness on raising the head, palpitation of heart, especially 
at night, occasional trembling of the whole body, and ab- 
solute inability to walk. 

The man was slenderly built, of medium height, in moder- 
ate nutrition; pale of face and mucosae; pulse small, regular, 
and 114. Neurologically, the deep reflexes were generally 
increased, and the skin reflexes decreased. Percussion on 
the back of the head elicited marked pain. There were no 
pressure points. The movements of the arms were free; 
there was a marked tremor of both hands, more marked on the 
right. The left grasp was 45, the right, 20, by the dynamom- 
eter. 

When lying upon his back, the patient could move his 
legs, but he moved them only slowly and with tremor. The 
heel-to-knee test was successfully executed despite the 
tremor; nor could it be demonstrated that there was a 
genuine ataxia. Placed upon his feet, he would collapse, 
nor could he be made to walk at all. With trunk supported, 
he was able to make only a few unsuccessful attempts to drag 
the feet forward. 

Associated with this apparent paralysis, the sensitiveness 
to touch had entirely ceased in the legs, as well as sensitive- 
ness to pain. The zone of analgesia, however, was more 
extensive than the anesthesia, spreading upwards three or 
four cm. farther in front. Ticking of the watch could not be 
heard even at the meatus of the right ear, although hearing 
of the left ear was entirely normal ; bone transmission on the 
left side. Whispers could be heard close to the meatus. On 
speaking, the patient stammered in starting sentences. 

He looked extremely anxious during the first few days in 
the Jena wards, claiming that he could not raise himself. 
When his trunk was raised, he would let himself sink feebly 
back into dorsal decubitus. However, when believing him- 
self unobserved, he was found to be able to move himself in 
bed somewhat quickly. He was able to get a box from be- 
neath the bed, to open the drawer of the night-stand, and to 
take remarkable care of his moustachios. He complained 



PSYCHONEUROSES 243 

more and more of headache, though his appetite and sleep 
were good. He was often irritable. 

Treatment at first consisted of cold packs of the legs twice 
a day, salt-water baths, active and passive exercises of the 
legs in the position of dorsal decubitus. The patient de- 
claimed against this treatment. There was slight improve- 
ment after a week of treatment. He was then able to raise 
himself in bed, seat himself on the edge of the bed, and stand 
without support, all the time, however, groaning and moan- 
ing. After a few moments, he would fall back on the bed, 
complaining of violent headache and dizziness. While stand- 
ing, both legs trembled. 



244 PSYCHONEUROSES 




Antityphoid inoculation : Neurasthenia. 



Case 180. (Consiglio, 1917.) 

A corporal, 39, began to be sleepless and weary, with head- 
ache, pains in the back, and dizziness. He was homesick. 
Upon hospital examination he was very variable in mood, 
rather hostile in attitude, and at the same time suggestible. 
He was so confident of being sent home that he anticipated 
the diagnosis by sending his belongings back to Sicily at the 
time he was transferred to hospital from his regiment. 

After a month's rest and psychotherapy, the man's general 
condition was greatly improved; he was no longer sleepless 
and had no longer any sign of neurotic disorder. He still 
maintained that his memory was weak, although in point of 
fact his memory was very good and quick. He could narrate 
all the facts about his neurasthenic state. The man's com- 
plaints were out of all proportion to any demonstrable somatic 
disorder. He was discharged, cured, to be put to work at 
shoemaking, with the diagnosis, neurasthenia. This neuras- 
thenic state developed after antityphoid injection. 

Re the occasional curious effects of antityphoid injection, 
see Case 65. 



PSYCHONEUROSES 245 



Neurasthenia (monosymptomatic : Sympathy with 
the enemy). 



Case 181. (Steiner, October, 191 5.) 

A non-commissioned reserve officer, 26, in civil life a mer- 
chant, had a strong hereditary taint, having been also in 
peace times very nervous and on that account obliged to 
give up his studies. At the age of 14, he had seen a man 
fall down from a roof and was much excited about it. 

At the beginning of mobilization he suffered a functional 
aphonia for a few days. He could not let his men shoot at 
the enemy because of an idea that occurred forcibly to him: 
that the enemy's soldiers had wives and children! He felt 
badly on this account. Later he had a constant taste of 
blood in his mouth and a smell of corpses in his nose. Toward 
nightfall all these symptoms would change for the worse, 
and the symptoms would become especially bad whenever 
he had anything to do with the wounded. He tended to 
weep much and was easily frightened and had also various 
physical symptoms of neurasthenia. 

Re the amazing sympathy with the enemy, see Case 229 
(Binswanger) and Case (Arinstein), in which chloroform 
lifted from a German and a Russian consciousness respec- 
tively opposite emotional tendencies. 



246 PSYCHONEUROSES 

Shell-shock CLAUSTROPHOBIA: Preferred shell 
exposure to shell-proof tunnel. 



Case 182. (Steiner, October, 191 5.) 

A colleague of Steiner, an army physician, 35 years of age, 
with strong hereditary taint, having two sick sisters (one 
dementia praecox) , had been incapacitated for work through 
a neurasthenia a few months before mobilization. However, 
at first he felt very well, marching through Belgium and into 
Northern France. 

On the night of the 17th of October, 19 14, a shell struck the 
house next where he was and startled him up out of sleep. 
After that, especially at nightfall, upon entering a cellar he 
would have the feeling of the ceiling falling down, and he 
would go restlessly from one space to another. Afterwards, 
any closed room, however secure or distant from the front 
and free from shells, would give him the feeling of the ceiling 
about to fall down. He could no longer sit quietly anywhere, 
but walked about and avoided the company of others. 

A characteristic observation is the following as described by 
the physician himself: There was an absolutely shell-proof 
tunnel running to the position at the front where he was on 
duty. It took about 25 minutes to go through the tunnel, 
but on account of his feelings he could not bring himself to 
use this tunnel but walked over the exposed hill which was 
frequently shelled. Curiously enough, after the appearance 
of the first symptoms, a shell exploded nearby without any 
marked psychical effect. This happened about noon. The 
obsessions were stronger in the evening. Objectively, there 
were neurasthenic symptoms of a bodily nature; there was 
vasomotor excitability. He was depressed, wept easily, and 
showed lack of decision ; he had tormenting thoughts that he 
had not fulfilled his duty. 



c 

XL PSYCHOPATHOSES 
(GROUP OF VARIOUS PSYCHOPATHIAS) 



A case of Pathological Lying occurring in a soldier. 



Case 183. (Henderson, July, 1917.) 

No. 27369, a private, attached to the 15th Battalion Dur- 
ham Light Infantry, was admitted Oct. 14, 191 6, to Lord 
Derby War Hospital from Netley. 

September 11, 191 6, he had been admitted to Number 3 
General Hospital, France, in a noisy, excited, insolent state: 
said he saw spirits of the dead ; heard his sister urging him to 
lead a better life. Admitted to Netley early in October, 191 6: 
now said he was a spiritualist, a Frenchman, had a quarrel 
with parents and enlisted in British Army, in army service; 
went to France August 12, 1914, was wounded at Loos, Sep- 
tember, 1915, returned to front in February, 1916, "shell- 
shocked" June 1, 1 91 6; lost consciousness after this — did 
not know where he was until July 22, 191 6, when he had 
been arrested as deserter. 

Admitted to Lord Derby Hospital October 14, 191 6, — 
quiet, orderly, cooperative : desired to return to his regiment. 
He now gave a history: Enlisted British Army 1908, went to 
France, August, 19 14, wounded February, 191 5, at Neuve 
Chapelle; recovered; then attached to 45th Durham Light 
Infantry; blown up July 22, 1916, came to August 5, 1916, 
in hospital in Boulogne; then back to his regiment — but 
month later left without leave to pay off old score on a former 
comrade who had insulted his sister — arrested later by 
military police; put under observation in 65th Field Ambu- 
lance. No deterioration noted, school knowledge fairly well 
retained; no hallucinations or delusions (maintained he was 
a spiritualist, also that following shell-shock had suffered from 
insomnia and seemed to hear sister's voice). Physically^ — 
small, well nourished, effeminate looking. 

Oct. 23, 1 91 6, he broke parole, but a month later returned 
to hospital under arrest. The police reported he had been 

247 



248 PSYCHOPATHOSES 

masquerading as wounded French soldier attached to British 
army as interpreter; imposed on people; had two leaden 
types in his possession: "Interpreter R. le Auldere, attached 
to 1st Di vision.' ' 

Story in hospital on return : — Born in France, did well in 
school, entered military academy at Paris. Quarreled with 
father — ran away to sea. Adopted by a French lady at 
Pembroke Dock. On account of drunken habits, quarreled 
again; joined army at Bristol, 1908. Went to France in 
August, 1914; January, 1915, invalided home because of 
" trench feet" — discharged as unfit. Reenlisted June, 1915, 
in Durham Light Infantry. January, 1916, again ordered to 
France. Blown up on Somme, July, 1916, by shell — remem- 
bered nothing until brought to No. 3 General Hospital. He 
remembers being accused of desertion but sentence was not 
passed, as he was held by the medical officer to have been 
irresponsible (as a matter of fact he was, at that time, 
considered to be a case of dementia praecox.) 

Said that during twenty- five days, due to drunkenness, his 
friends had taken him to Manchester with them ; arrested by 
police as he attempted to get back to hospital. He was now 
accused of wilfully lying and, confronted with his police 
record, at first denied it, but later gave following approxi- 
mately true story : 

Born, England, 1890; early life of a roving disposition, 
good at school, liked books of adventure. Drank early. 
Ran away at sixteen; was returned home. Ran away again 
— convicted of drunkenness. Three-year sentence to re- 
formatory in 1 9 10 for stealing: escaped. Rearrested for 
stealing in 1911: released in 191 3, enlisted in army and de- 
serted. Arrested in January, 1914, for stealing; sentenced 
to three years: released to rejoin army in June, 1915. 
Arrested as deserter: imprisoned but released in January, 
1 9 16; left for France. August, 1916, "shell-shocked," sent 
to Field Ambulance No. 3, General Hospital, Netley, and 
Lord Derby War Hospital. Court-martialed for desertion: 
nothing came of it on account of medical evidence. 

After breaking his hospital parole, he masqueraded in 
district as "R. le Auldere," "Le Marchal " and imposed on 
various persons. 



PSYCHOPATHOSES 249 

Psychopath almost Bolshevik. 



Case 184. (Hoven, 1917.) 

A sergeant, accountant in civil life (father insane, mother 
pulmonary, grandfather alcoholic, cousin insane; patient 
himself anemic as a boy, victim of chronic gastritis and 
gonorrhea), was evacuated from the front to Chateaugiron in 
March, 19 16. It appeared that instead of watching over his 
men as a sergeant should, he gave utterance to baroque 
theories of the divine right, the influence of the grace of God 
on man, and the end of the war. He went so far as to ask 
leave to transmit to the Inventions Bureau of the War 
Ministry an invention with respect to the problem of loco- 
motion, and he sent to the King of Belgium a manuscript to 
the effect that he had received from heaven a mission to 
reestablish the world's balance. He was, in fact, the victim 
of delusions of a mystical nature with visual hallucinations. 
To explain his mission, he wrote, "It was my duty to take 
supreme command of war operations. ... I have the power, 
the right and the duty to give the following order . . . 
general armistice . . . peace will be symbolized by the house 
undivided and will be constituted by general Christian relig- 
ious unity ... as a consequence of what we shall say they 
will give up our territory to us of their own accord." 

This case of paranoia apparently took its coloring in part 
from the war situation itself. 






25O PSYCHOPATHOSES 

Hysterical mutism : Persistent delusional psychosis. 



Case 185. (Dumesnil, 1915.) 

A sergeant, aged 23, evacuated from the front to a hospital 
for the insane, had been mute, though not deaf, since Febru- 
ary 28, 1 91 5. If asked to cry out he grew black in the face 
and could utter only a raucous scream which made everyone 
jump. He wrote very frequently, stating in February that 
as he was still a sergeant and had no hope of advancement, 
he cared nothing more for life. "The idea of death got 
anchored in my head." In this state of mind, on the after- 
noon of the 27th two bombs came. "I saw the first one 
coming and cried out a warning. Coming back I saw the 
second one. The bombs were coming rather softly. From 
this moment on and up to the time when they burst, I thought 
I had gone, that I had been carried off and crushed. I was 
quite astounded at finding myself covered with earth and 
stones . . . but I could not talk any more, I could just say 
in a low voice 'Papa,' and the next day in an ambulance I 
could not talk at all." 

There was complete pharyngeal anesthesia. The man had 
been a foundling and was clearly a degenerate. He had 
always been of a depressed disposition and given to thoughts 
about his misfortunes. Over and above the mutism gradu- 
ally ideas of persecution and revindication developed (such 
as that he merited adjutant's rank and was being mocked and 
treated as a simulator) . He drew up a long letter to the War 
Ministry in which he stated his desire to be sent back to the 
front. He complained to the police about a hospital sergeant 
and offered a duel in an elaborate and inflammatory style, 
"with whatever weapons shall please you, either sabre of 
1845, revolver of 1902 or bayonet of 1886 or the chassepot. 
One of us two must disappear." He had become dangerous 
enough to be interned and in hospital remained mute with the 
same ideas of persecution and revindication, the same alter- 
nate phases of calmness and excitation. According to Dumes- 
nil : hysterical mutism with persecutory delusional psychosis. 






PSYCHOPATHOSES 25 1 



A peasant's psychopathic inferiority brought out by 
the war. 



Case 186. (Bennati, October, 1916.) 

An Italian peasant began to feel sick on being called to 
arms. Antebellum he had been an even-tempered, good- 
natured man, according to his own story, satisfied even with 
stale food, and always enjoying his sleep. He had been in 
the war about a month, doing construction work, sentry duty, 
and chores. Though he lived in the trenches under damp 
conditions, there had really not been much excessive war 
strain. He shortly developed migraine and war-weariness, 
as well as middle-ear disease. 

A number of times he heard shooting nearby, and was sub- 
ject in his sentry duty to a good deal of anxiety and pain- 
ful associations. On sentry duty he had digestive disorder, 
vomited, and became intolerably weary; in point of fact, a 
fever, regarded as malarial, then developed, together with 
diarrhea. 

Upon hospital observation, he was found fatigued, given 
to terrible dreams, tremulous in the fingers, with skin reflexes 
a little excessive, and the Moebius phenomenon. The 
thyroid was somewhat swollen. The pulse stood at 80. 
The Mannkopf sign was well marked, as well as that of" 
Thomayer (80-120), and Erben (120-87). The oculocardiac 
reflex was prominent. 



252 PSYCHOPATHOSES 



Psychopathic episodes. 



Case 187. (Pellacani, April, 191 7.) 

A Neapolitan, 26 (neuropathic stock: mother epileptic, 
brother psychopathic; patient had previous criminal record; 
married and then appeared to behave himself for several 
years; had always been excitable and of violent temper), 
after but one severe day in the trenches, woke and found his 
night clothes soaked in urine. Another time, his comrade had 
awakened him because he was gnashing his teeth in his sleep. 
Again, his grief became very violent at learning of his wife's 
infidelity, and during the night he bit his finger. He there- 
after suffered from severe headaches, dizziness and vertigo 
though without falling. He was granted a furlough, but the 
condition was aggravated on account of his wife's abandon- 
ment of him, and one day, finding her with her lover, he threw 
himself at them, wounding her severely in the face : he did not 
remember this impulse later. Many hours later, on awaken- 
ing in prison with his wounded hand, he recalled the entire 
episode. He showed a confused and excited condition, 
which, however, quickly diminished. He became lucid and 
tranquil, though easily aroused. He cried at the thought of 
his daughter, whom he wanted to save. Insomnia, insta- 
bility of reaction, habitual migraine, and dizziness. Tremors 
of the fingers and of the eyelids. Exaggerated reflexes. Very 
striking cutaneous analgesia. 



PSYCHOPATHOSES 253 



Maniacal and hysterical delinquent. 



Case 188. (Buscaino and Coppola, January, 191 6.) 

An Italian soldier, 25, a foundling, was always off and on 
in a military prison. At a tavern one night the man un- 
sheathed his sword and threw three bottles at the host. 
Bystanders overpowered him and carried him to the local 
police station. Handcuffs were put on to stop the mania. 
His pupils were dilated and he was sweating profusely. 
Alcohol could absolutely be excluded from the history of this 
incident. 

Observed in clinic, the patient was rather silent, but on 
the whole normal and without delusions or hallucinations. 
It seems that he had committed a number of crimes in the 
army that were always excused on account of his mental state. 
He had been strongly alcoholic, although not at the time of 
the incident mentioned. He was covered with tattooings of 
an obscene and violent nature. 

He showed pharyngeal and conjunctival anesthesia and 
concentric limitation of the visual fields of unusual degree, 
and a remarkable hypalgesia. The knee-jerks were lively. 
The man was, in point of fact, sent back to military service, 
with, however, the suggestion of reform school. 



254 PSYCHOPATHOSES 

Psychopathic delinquent. 



Case 189. (Buscaino and Coppola, January, 191 6.) 

An Italian, 20 (family history negative), was described by 
officers as of an odd disposition, at times thoughtful and again 
chattering and presumptuous, and often very vulgar in talk 
and manner. He had tried several trades, with little success. 

While in the army he discharged his gun three times, claim- 
ing to have heard noises in a nearby field. On account of the 
inopportune repeated discharges, he was condemned to the 
barracks for ten days. The following day, instead of return- 
ing to the barracks, he abandoned his musket, cartridge box 
and uniform, and, returning to town, left for Leghorn. Being 
sent to prison, he began to scream that he was thirsty. He 
tore his jacket into strips with his teeth, and making a noose 
of it, attempted to hang himself. 

On being transferred to the military hospital, he was often 
very restless, screaming and making a great uproar. On 
being questioned, he answered indifferently and had a vacant 
stare. During his stay at the clinic, patient was always 
quiet. Once, however, he had a spell of intense psycho- 
motor agitation, brought on without any known cause and 
followed by a short period of bewilderment, lasting altogether 
half an hour. 

Patient had insomnia and his visual fields showed con- 
centric contraction for white. He was sent to a military 
convalescent hospital. 



PSYCHOPATHOSES 255 

Psychopathic excitement. 



Case 190. (Buscaino and Coppola, January, 1916.) 

An Italian soldier, 22 (father and brother both committed 
to insane asylums), since his enlistment had been conduct- 
ing himself strangely, being impulsive, undisciplined and 
unbalanced. He had been in Libia from January to August, 
191 3, and was returned to Italy on account of persistent severe 
headaches. A month later he was returned to a regiment 
in camp. 

September 23, 19 14, the patient, who had been reproved 
by a superior officer to whom he had given a disrespectful 
answer, began to be excitable. He was calm during the day, 
but acted in a sullen and gloomy way and kept entirely to 
himself, avoiding even his most intimate friends. When, 
however, he suddenly recalled his punishment of the morning, 
he began to race around the yard and finally threw himself 
upon the ground, remaining there in a cowering and squatting 
position. At the beginning of the attack he was possessed 
of a paroxysm of fury, which made a great impression upon 
those present: eyes agape, face swollen and distorted. He 
resisted being transferred to the hospital and a furious 
struggle followed. He tried to bite and scratch everyone. 
It required ten persons to carry him by his hands and feet 
safely to the hospital, where he arrived in a state of great 
excitement and rage. 

At the clinic, during the period of observation, he was 
always tranquil, rather silent, gloomy, somewhat hostile; 
said he did not remember why he was brought there. Often 
he was not able to sleep, especially during the first few days 
of his stay. Has had painful headaches and feeling of dizzi- 
ness. Several times he showed a tendency to be untruthful. 
Bodily examination revealed the absence of conjunctival and 
pharyngeal reflexes. W. R. of serum was negative. 

Patient was sent to an interior hospital for convalescence. 



256 PSYCHOPATHOSES 

Desertion: Dromomania. 



Case 191. (Consiglio, 1917.) 

An Italian private, 19, came up for desertion in the face of 
the enemy. He had had a good record during a year of 
military service and his army conduct in the war was regarded 
as very good. 

He felt sad and preoccupied for a number of days, but all 
of a sudden "some indomitable force " thrust the idea into 
him to go out into the country a distance of some 20 kilo- 
meters from the front, with the definite object of praying in 
a certain church. It seems that this same impulse had 
occurred to him several times before but not so forcibly. 
These prayers were to be said in memory of some sad events 
in his life. 

Upon examination he was found in a sad and self-accusa- 
tory state, much discouraged with ideas of his guilt, un- 
worthiness, and ruin. He had a variety of gloomy fears and 
obessions, all of which contributed to the dromomania that 
culminated in desertion. 

As to his previous history, he had had a depressive psy- 
chosis two years before, but the delusions at that time were 
of persecution. He had also suffered from typhoid fever a 
few weeks thereafter. 



PSYCHOPATHOSES 257 

Suppressed homosexuality. 



Case 192. (R. P. Smith, October, 1916.) 

A man, 32 years, of high intellectual attainments and un- 
blemished moral character — a teacher — enlisted as a private. 
He apparently found his associates in camp very uncon- 
genial and undesirable. He grew physically tired, then 
mentally tired and unable to concentrate attention. He 
began to neglect his uniform, could not keep his equipment 
in order, became introspective and depressed. The drums 
he heard seemed to point to his funeral. There was but one 
thing to do in his opinion : that was to humiliate himself by 
committing sodomy. He thought of committing suicide. 

Upon discharge from military duty, he began to show 
improvement. Smith regards this case as one of suppressed 
homosexuality. 

Of the cases in which change or excessive work is the pre- 
cipitating cause, four out of six of Smith's cases were men. 

Re homosexuality in the Italian army, Lattes has made a 
special study. The effeminate homosexual is decidedly unfit 
for the army, being unable to stand the war stress. Homo- 
sexuals diminish army morale. The cases of functional 
effeminacy with normal physique are likewise unfortunate 
for the morale of active units, though they may be employed 
in garrison duty and office work. The medical decision in 
these cases may prove difficult unless a broad interpretation 
of the concept " psychopathic " is allowed to prevail. 



258 PSYCHOPATHOSES 

Psychopathic : suicidal, then self-mutilative. 



Case 193. (MacCurdy, July, 1917.) 

An English soldier as a child had night terrors and fear of 
the dark; as a youth wanted to throw himself down from 
heights; took delight in seeing animals killed; was shy with 
both sexes ; was never able to run great distances ; was taken 
from school at the age of fifteen for weakness, and had always 
been subject to headaches, somewhat improved by lenses. 

During training sharp pains appeared in the left groin that 
grew better when the man lay down. These pains were 
regarded as hysterical. Thereafter began shortness of breath, 
pain above the heart, with palpitations and occasional attacks 
of dizziness. After a short sick leave he insisted upon going 
to the front, though his superior officer thought it unwise, 
and, after a period of seventeen months training, was finally 
sent to France in September, 1916. 

He was at first somewhat afraid of shells and, though he 
soon got used to the shells, the horror of the war grew on him, 
with pity for the Germans as much as for the British. He 
became depressed over his weakness and when his command- 
ing officer committed suicide got obsessed with the idea of 
committing suicide himself. He went so far as to drive a 
knife into his upper lip and to smash a looking-glass to avoid 
seeing himself. After a long spell of trench duty he had to 
be sent home incapacitated. 

In hospital in England he was depressed and suicidal. 
He began to want to mutilate himself, yet found that a slight 
pain and the drawing of blood was all that he really craved. 
Of course, he had been a failure, but now he rationalized the 
failure by a comfortable conviction that he should never have 
been sent to the front. He complained of memory and 
attention disorder, insisted that he was physically incapable 
of outdoor exercise, complained of headache if he stayed 
indoors. He said he wanted to go back to the front; knew, 
however, that he could not, and even refused to consider the 
possibility of getting well to work at home. At the time of 
report he argued there was nothing left but suicide. 



PSYCHOPATHOSES 259 

Bombardment : Psychasthenia? 



Case 194. (Laignel-Lavastine and Courbon, July, 
1917.) 

A twenty-year old engineering student of high grade and 
without hereditary taint, a scientific and non-introspective 
man of a brilliant and gay disposition, not very religious, with- 
out special sexual abnormality, was mobilized in class 1914, 
was put into the artillery, and was soon appointed marechal 
des logis. He left for the front April, 191 5, yet had to be 
evacuated in November. One afternoon, at the end of a 
bombardment, he rose from a recumbent attitude and imme- 
diately felt a dreamy, bizarre feeling, as if a fog lay between 
him and his surroundings. Next day, after a good night, 
he woke in the same state. Everything was bizarre and 
novel despite the fact that he recognized men and things. 
A physician ordered rest and after a few days evacuated him. 

He was cared for in various hospitals, but the psychas- 
thenia increased. He felt a terrible and causeless anguish, 
with precordial constriction. He felt as if he were about 
to be executed. His fears appeared after seeing some turn- 
ing object, such as a wheel or a cane twirling. Gradually 
this fear was transformed into a genital excitation, though 
lascivious pictures did not excite him. Seeing anything 
turning gave him a voluptuous feeling in proportion to the 
speed of the rotation. It seems that all sexual interest 
had been at a standstill for several months in the early 
part of his disease, when suddenly this new aberration 
appeared. It seems that a portion of the man's work in the 
artillery caused him to use screws and cogwheels every 
day. Attacks of vertigo occurred, with the appearance of an 
infinity of small, colorless spheres turning over one another, 
the whole forming a sort of animated system of rotation. 
In the night this system was luminous and somewhat like 
what one feels on compressing the globes of the eye. There 
was a retraction of the visual field. The man would be found 
in the dream state, especially after waking in the morning 
or when some novel kind of act was being performed. He 






200 PSYCHOPATHOSES 






got somewhat better and did not wish to go on leave, be- 
cause he feared the recurrence of these psychasthenic par- 
oxysms. However, he took a leave July 14th. In the first 
part of his journey he had some vertigo and some of the 
voluptuous sensations, but in the next two days he was 
much better. He returned to hospital without trouble. 

The authors somewhat doubtfully term this case one of a 
quiet psychasthenia, but in discussion still further talk arose 
as to the diagnosis. 

Re psychasthenics, Lepine notes that the lack of any out- 
standing symptoms in many psychasthenics allows them to 
stay in the army longer than would epileptics or hysterics 
of the same degree of disease. The line officers tend to 
consider them exaggerators or simulators. The fact that 
they besiege the line officers and the physicians with their 
troubles may add to the impression of falsification. The 
basis of the psychasthenia is often also, genuinely enough, a 
fear. Lepine divides the military cases into anxiety neu- 
roses and hypochondrias. The anxiety cases are hypo- 
tensive and given to tachycardia. They have very labile 
vasomotors. When it comes to the necessary exclusion of 
malingering, it is the history, with its hereditary and col- 
lateral taint, that tells the tale. A history in the patient 
himself of alcoholism, typhoid fever, syphilis, or especially 
cranial trauma may play a part. An agoraphobic may actu- 
ally be in general a courageous man except for his crises of 
anxiety about open spaces. 

As to the hypochondriacs, fear of syphilis must be noted. 
Akin to the syphilophobics are a group of pseudo genito- 
urinary cases that fear effects of an old gonorrhoea. See 
Case 195 (Colin and Lautier) below. 



PSYCHOPATHOSES 26 I 



Gonorrhoea: NOSOPHOBIA, depression, suicidal 
attempt. Recovery, thirteen months. 



Case 195. (Colin and Lautier, July, 1917.) 

A munition worker came to Villejuif, December 6, 191 5, 
with cord marks on his neck and conjunctival ecchymoses. 
He had tried to hang himself. 

Non-alcoholic, he had, however, long since shown signs of 
imbalance; his father had died insane, in an institution. 
When the man came in, he wept and groaned and made 
vague complaints of having contracted a venereal disease, 
insisting that his genital organs were purple. 

After a few days, he grew less anxious and told how he was 
married and how his wife had made life a hell for him, giving 
herself up to drink and becoming a sloven; how several 
months since he had contracted gonorrhoea; how though 
told that the condition was cured, he had found filaments in 
the urine and had tried a variety of drugs, spending most of 
his money; how he found more and more filaments, thought 
himself incurable and unable to live with his wife; how at 
last, desperate, he had tried to hang himself. 

He got well quickly, though his convalescence was in-' 
terrupted by several periods of depression a few days in 
duration, with anxiety and tears. February, 191 6, he was 
discharged well. 

He returned four months later; he was still occupied with 
his disease, still going to physicians and buying drugs. It 
took six months more before the man could be discharged 
from the service, at the end of 191 6. 

This man appears to be a hereditarily predisposed subject, 
who simply affixed his delusional ideas to a disease which had 
begun some time before the mental trouble itself. The fam- 
ily plight is important and practically constant in this group 
of cases. The fear lest the disease shall be revealed by the 
physician to the family is deep-grounded and impossible 
to overcome by mere statements concerning professional 
secrecy. The impulse to suicide is extraordinarily keen. 



262 PSYCHOPATHOSES 



A soldier (neuropathic taint) after hardships for two 
days stumbles over a corpse; unconsciousness: 
Stupor ; episodes of fright with war hallucinations ; 
look of premature old age ; paresis ; anesthesia. 



Case 196. (Lattes and Goria, 191 7.) 

An Italian soldier (a shoemaker with an epileptic mother 
and two nervous brothers; himself always irritable and for 
long periods melancholic; at 15 condemned to nine years 
in prison for homicide in a quarrel) took part in a num- 
ber of attacks at the beginning of the war. His company 
was heavily engaged in October, 191 5, and there was no sleep 
two nights, and only a bit of cold food. He was dazed. 

October 24, the company had to advance at night in the 
rain and under a heavy rifle fire. The shoemaker stumbled 
over a corpse, fell, and lost consciousness for a time that 
he thought was very long. He woke up in a camp hospital, 
remembering all the experiences he had undergone up to 
the time of losing consciousness. He now fell into a state 
of torpor, occasionally jumping out of bed and shouting with 
fear, hurling himself at non-existent persons, assuming a 
position of defence, and suddenly awaking in anxiety. 

October 29, he was transferred to a second hospital, and 
October 30, in a third hospital, was examined and found 
well and strongly built, but looking prematurely old. He 
was inactive, depressed, and stuporous looking. He fell to 
weeping often and rarely gave any answer to questions. 
Sometimes he refused food. There was a slight paresis of 
the left arm, and the left pupil was smaller than the right; 
both pupils reacted poorly to light. The larynx and cornea 
did not respond to stimulation. Skin reflexes were poor, 
and the plantar reflex lacking. The left side about the 
shoulder and hip showed large patches of anesthesia to touch, 
pain and heat; but deep sensibility was present in these 
areas. He slept well at night. Status unchanged for two 
weeks. He was experimentally sent to the guardhouse, but 
was soon back in hospital with the same symptoms as ever. 



— la buia campagna 
tremo si forte, che dello spavento 
la mente di sudore ancor mi bagna 

La terra lagrimosa diede vento, 
che baleno una luce vermiglia, 
la qual mi vinse ciascun sentimento; 

E caddi, come l'uom, cui sonno piglia. 



— the dusky plain 
trembled so violently, that the remembrance 
of my terror bathes me still with sweat. 

The tearful ground gave out wind 
which flashed forth a crimson light 
that conquered all my senses; 

And I fell, like one who is seized with sleep. 

Inferno, Canto in, 130-136. 



264 



B. SHELL-SHOCK: NATURE AND CAUSES. 



Bombardment; shell explosion nearby: Mania; 
death in 24 hours. The AUTOPSY showed super- 
ficial punctate hemorrhages of brain and congestion 
of pia mater. CAUSE OF DEATH — small bulbar 
hemorrhage, congestion of veins, and nerve-cell 
changes of a local and differential nature (chro- 
matolysis of vago-accessorius nucleus). SHELL- 
SHOCK SYMPTOMS due to capillary anemia and 
chromatolysis of various regions. 



Case 197. (Mott, November, 191 7.) 

A soldier became rather nervous at the Somme, and later 
underwent intense bombardment for some four hours, Feb- 
ruary 22, 4 to 8 P.M. Although he said he " could not 
stand it much longer " he carried on for twelve hours more 
when perhaps six shells went over, February 23. One of 
the shells burst about ten feet away, just behind the dugout. 
The first day of the bombardment he was tremulous and 
depressed; later coarsely tremulous in the limbs. February 
23 there was crying and inability to walk or do any sort of 
work. Questions were not answered. The pupils were 
dilated. The evening of February 23 the man was admitted 
to the field ambulance in acute mania, shouting: " Keep 
them back! Keep them back! " He was quieted with mor- 
phine and chloroform and slept well during the night. There 
were at least two hypodermic injections of morphine in the 
ambulance. He woke up the morning of February 24 ap- 
parently well, but suddenly died. 

The autopsy showed small scratches on the anterior chest 
wall, but otherwise no sign of external violence. Both lungs 
were edematous; the left lower lobe showed a considerable 
hemorrhage. The heart was enlarged and the right side 

265 



266 SHELL-SHOCK: NATURE AND CAUSES 



EFFECTS OF HIGH EXPLOSIVE SHELLS 

EMOTIONAL 

COMMOTIONAL 

LESIONAL 

After Vincent and others 



Chart 7 






SHELL-SHOCK: NATURE AND CAUSES 

SHELL,- SHOCK 



267 



SUGGESTION 

(AUTO-, HETERO-, MEDICAL) 


ESSENTIAL! 

(Babinski) 

SOMETIMES SOLE 
FACTOR? 


""3 


k 




> 


k 




EMOTION 




SHOCK 


INTRABELLUM 

FACTORS 

USUALLY 

ONE OR 

BOTH 


i 


k 


I 


t 


1 












SOIL 

(acquired , antebellum) 


FREQUENT BUT 
NON-ESSENTIAL 




< > 










TAINT 

(hereditary) 


FREQUENT BUT 
NON-ESSENTIAL 



Chart 8 



268 shell-shock: nature and causes 

dilated. The liver was somewhat congested. The kidneys 
were small, but otherwise showed no gross change (urine 
without sugar or albumin). 

The scalp showed a slight frontal bruise. The brain was 
extremely congested. On each side of every superficial 
vessel there was an ecchymosis. A number of minute 
punctate hemorrhages was found on the surface of the 
brain in connection with very small vessels. The brain 
substance was soft, but not markedly edematous. The 
cerebrospinal fluid was tinged with blood. On each side of 
the great sinuses of the skull there was considerable ecchy- 
mosis. This examination was made by Capt. A. Stokes, 
R.A.M.C., in the mobile laboratory. There were no areas of 
large hemorrhage anywhere in the brain substance and no 
smaller petechiae, except the superficial ones above noted. 

Microscopically Mott confirmed the pial congestion and 
macroscopic subpial hemorrhages described in the gross. He 
found besides congestion also actual hemorrhage in the vas- 
cular sheaths of the corpus callosum, internal capsule, pons 
and bulb. Now and then blood corpuscles were found ex- 
travasated into the nervous tissue. 

The microscopic examination showed a generalized early 
chromatolysis in the nerve cells of varying intensity, espe- 
cially affecting the small cells. The Nissl granules of the 
larger cells were also somewhat abnormal, being smaller and 
packed rather loosely together. 

The small cells of the bulb and pons were slightly swollen 
and their nuclei large and clear. As to the larger cells of the 
bulb and pons, there was less evidence of this swelling and 
nuclear change. 

According to Mott, this chromatolysis may perhaps be re- 
garded as a sign of loss of biochemical neuropotential. 
The chromatolysis indicates a relative degree of exhaustion 
of the kinetoplasm. Mott assumes that the cells of this 
victim of shell-shock are in a state of beginning nervous 
exhaustion. He remarks that the cells of the vago-acces- 
sorius nucleus show more signs of this nervous exhaustion 
than others. With respect to cerebellar findings Mott re- 
marks that the changes found are very similar to those 






^jg*4:'?k *' :. ■ .' * 










Punctate hemorrhages in corpus callosum from a case of 
shell-shock and burial; very probably accompanied by gas 
poisoning while lying unconscious and buried. Observe the 
small white area in the centre of the haemorrhage, in the 
middle of which is a small vessel which, under a higher 
magnification, will be seen to contain a hyaline thrombus. 
(X 20.) 







m 




Hyaline thrombus of vessel in centre of a punctate 
haemorrhage. The thrombus was stained brown by 
dissolved pigment. Around the blocked vessel is a 
white area of brown substance containing numbers of 
leucocytes; outside this is the haemorrhage, not very 
distinctly seen, xhe specimen was prepared from the 
subcortical white matter of the frontal lobe. (X 345-) 







vJ*k 







Three punctate haemorrhages showing optostriate arteri- 
oles filled with pigment granules. (X 30.) 



Leash of small perforating optostriate arteries filled 
with pigment granules. Two of the arterioles show 
miliary aneurisms. (X 35°-) 

HISTOPATHOLOGY OF CASE OF SHELL-SHOCK, BURIAL, 
GAS POISONING ? (F. W. MOTT) 




TWOfe 



Fig. i. — Photomicrograph of section of corpus callosum 
from case of shell-shock showing the capillary punctate 
haemorrhages. In several a small white area is seen of 
brain tissue in the centre of which is a small artery or 
vein. (Magnification 20 diameters.) 



^ 



c 



% 



Fig. 2. — Section of medulla oblongata from case of gas 
poisoning, stained byNissl method, showing the swollen 
cells of the nucleus ambiguus. Observe the enlarged, 
clear, eccentric nucleus; the surrounding cytoplasm 
shows an absence of Nissl granules. In not a single cell 
is the nucleus seen in the centre as it should be. (Mag- 
nification 450.) 




f 






.«£ 



K -', 



«r* 



Fig. 3. — Section of medulla oblongata from case of shell- 
shock with burial, stained by Nissl method, showing 
the swollen cells of the nucleus ambiguus. Observe the 
enlarged, clear, eccentric nucleus; the surrounding cy- 
toplasm shows an absence of Nissl granules. In not a 
single cell is the nucleus seen in the centre as it should 
be. (Magnification 450.) 






i 




\ 

Fig. 4. — Section of third cervical segment of spinal cord 
from case of concussion, stained by Nissl method, 
showing the medium group of anterior horn cells corres- 
ponding to the nucleus diaphragmaticus. They show 
certain amount of perinuclear chromatolysis. But all 
the cells exhibit the Nissl granules. Even at the seat of 
concussion.the fourth segment, an external group of cells 
remains snowing Nissl granules. Concussion there- 
fore does not destroy the Nissl granules. Probably the 
cells of the nucleus diaphragmaticus show a certain 
amount of chromatolysis because they were continually 
discharging impulses along the phrenic nerves, and the 
few cells that were left of the nucleus had therefore 
much more work to do. (Magnification 300.) 



HISTOPATHOLOGY OF SHELL-SHOCK (F. W. MOTT) 



JOTE THAT THE CHANGES IN CELLS OF FIG. 3 ARE DIFFERENTIAL FOR NUCLEUS AMBIGUUS 

CELLS NEARBY PROVED NORMAL 



shell-shock: nature and causes 269 

described by Crile in the case of an exhausted and wounded 
soldier. Mott correlates the mania shown on the evening of 
February 23 with the venous congestion of the cortex, the 
small subpial hemorrhages and evidence of scattered arterio- 
capillary collapse. 

Mott suggests that the sudden death of the case may be 
due to a hemorrhage into a sheath of a fair-sized vessel in 
the median raphe of the bulb ; the general venous congestion ; 
and the almost complete chromatolysis of the vago-accesso- 
rius nucleus (adjacent hypoglossal nucleus normal). 

According to Mott, also, many Shell-shock symptoms, e.g., 
headache, giddiness, amnesia (anterograde and retrograde), 
dizzy feelings, lack of power of attention, and fatigue, stupor, 
inertia, mental confusion, terrifying dreams, are to be ex- 
plained on the basis of capillary anemia and chromatolytic 
changes. 



270 SHELL-SHOCK: NATURE AND CAUSES 






Mine explosion. Ecchymoses; no bone or visceral 
consequences seen at AUTOPSY (third day after ex- 
plosion) except SUBDURAL HEMORRHAGE and 
PUNCTATE HEMORRHAGES OF BRAIN. 



Case 198. (Chavigny, January, 1916.) 

A sergeant in a Chasseur Battalion was in a mine explo- 
sion and entered hospital June 19, 19 15, so agitated that he 
had to be tied to the stretcher during transfer from the 
railway. There were remains of epistaxis and blood in the 
right ear, not proved to be due to otorrhagia; blue-black 
ecchymoses of both eyelids; and small ecchymoses of the 
bulbar conjunctiva of the right eye. No other sign of 
trauma or fracture. The explosion had probably taken 
place on June 17 or 18. Patient was but semiconscious and 
irresponsive;' rolled upon the mattress, beating the air with 
arms and legs, assuming fighting postures and uttering cries. 
Urinary incontinence. No fever. 

There was doubt as to the diagnosis, which lay between 
fracture and concussion. The persistent agitation and oniric 
delirium pointed rather to concussion. Without further 
sign, however, the patient died on the night of June 20. 

The autopsy was extremely careful and showed no sign of 
cranial fracture of vault or base. The cerebrospinal fluid 
was strongly bloodstained. The inner surface of the dura 
mater had a thin sheet of hemorrhage, hardly 1 mm. thick, 
covering both hemispheres and the cerebellum and spreading 
over the bulb. There was no distension of the lateral ven- 
tricles. Serial sections of the brain showed no lesions of 
the substance, except for slight hemorrhagic points. 

According to Chavigny, so slight a meningeal hemorrhage 
is incapable of producing a mechanical disturbance of the 
brain and the cause of death could not be said to be men- 
ingeal hemorrhage. Massive multiple gas embolism through 
sudden decompression is not a suitable explanation of a case 
with death delayed, as in this instance, even if Arnoux's ex- 
planation is suitable for cases of immediate death. 



shell-shock: nature and causes 271 



Mine explosion: no skin, bone, or visceral con- 
sequences seen at AUTOPSY (death in seven 
days) except slight LOCALIZED MENINGEAL 
HEMORRHAGE. 



Case 199. (Roussy and Boisseau, August, 1916.) 

A soldier entered Val-de-Gr&ce February 27, 1915, in a 
state of confusion following mine explosion the night before. 
He was delirious, thought himself on leave, and had spells 
of excitement. Lumbar puncture, February 29, showed a 
slightly darkened fluid, with approximately normal amount of 
albumin, one or two lymphocytes and rare red blood cells. 

A brief period of slight improvement followed, but the 
restlessness and delirium increased once more, became par- 
ticularly severe March 3, and the patient died on the night of 
the third, seven days after the explosion. 

The autopsy showed slightly congested lungs; no other 
lesion except a sharply defined hemorrhage in the cervical 
spinal meninges and over the meninges of the temporal 
and occipital lobes. Microscopic section of the brain failed 
to show any hemorrhages within the brain substance. 

Here is a case of death following explosion without external 
wound. The meningeal hemorrhages are hardly enough to 
explain the death. The explanation of the death must 
probably be made after histological examination. 



272 SHELL-SHOCK: NATURE AND CAUSES 



Concussion of spinal cord from shell burst — WITH- 
OUT spinal fracture, WITHOUT penetration of 
splinters of shell or bone into canal or cord sub- 
stance: Microscopic demonstration of intraspinal 
AREAS OF SOFTENING with classical secondary 
degenerations. Such a case forms a link in the ar- 
gument that serious lesions of the nervous system 
may develop as a result of VIOLENCE directly 
TRANSMITTED through investing tissues EN 
BLOC. 



Case 200. (Claude and Lhermitte, October, 191 5.) 

A man, 23, was struck in the left thorax and shoulder, in 
both thighs and the neck, by fragments from a bursting 
shell March 27 ', 191 5. One fragment was imbedded near the 
vertebral column. 

Twenty days later there was an absolute, flaccid para- 
plegia, yet the legs occasionally gave spontaneous, jerky 
movements. Tactile anesthesia reached the fourth dorsal 
root-level, except that the perineoscrotal region and the penis 
were somewhat sensitive. There was anesthesia to pain and 
heat, as well as in bones and joints, along with the tactile 
anesthesia. There was a hyperesthetic region on the right 
side, corresponding with the distribution of the fourth dorsal 
root. All the cutaneous reflexes up to the abdominals were 
gone; but defense reflexes could be brought out in foot and 
leg by skin, bone or joint stimulation. The deep reflexes of 
the legs were also lost, whereas those of the arms were in- 
creased. Retention of urine without incontinence; no re- 
tention of feces. Sacral, trochanteric and heel decubitus 
had developed in the course of the three weeks following 
injury. A lymphangitis ran all the way up the right thigh 
from one of the sores, with a corresponding hyperpyrexia. 

Surgical intervention was indicated from the evidence of 
spinal compression at a definite level, but the lymphangitis 
grew worse. Oniric delirium, and finally a stuporous state, 
set in, with death May 6, forty days after the wound, a death 



SHELL-SHOCK: NATURE AND CAUSES 273 

due to septicemia, without special alteration in the para- 
plegia itself or in the sensory and reflex situation. 

At autopsy the spine and dura mater proved normal ; but 
microscopically serial sections through the fourth and fifth 
dorsal segments showed softening of the right anterior horn 
and posterior columns, with cavitation in the radicular zones, 
and the white matter of the fifth dorsal segment was in a 
state of acute degeneration. There were also ependymal 
changes, namely, at the fifth dorsal level a dilatation with 
deposit of albumin; in the lumbar region, breakage of the 
ependymal wall, with cellular gliosis. The dilated ependyma 
was surrounded by an area of fibrillary gliosis which had pro- 
liferated in the form of a septum in the interior of the canal. 
(According to Claude and Lhermitte, these data concerning 
hydromyelia, which they regard as secondary to trauma, are 
an argument in favor of the traumatic origin of certain 
syringomyelias. They regard the breakage of the epen- 
dymal wall as due to hypertension of the spinal fluid due to 
mechanical lesions.) Their interpretation of such acute de- 
generation as was found in the fifth segment is that this 
degeneration, as well as that of the posterior roots, is due to 
the direct impact of the cerebrospinal fluid upon the cord 
structure. As for the softenings with cavitation, they re- 
gard them as surely due to spinal concussion and as very 
possibly due to an ischemic necrosis, suggesting that older 
work by Duret and Michel on concussion of the brain 
indicates the possibility of a temporary ischemia of the spinal 
cord from the violent impact of the spinal fluid upon the 
cord due to shock of the spinal column. The transient 
hypertension of the spinal fluid might well induce, they 
believe, a vascular spasm with anemia, to which the gray 
matter is well known to be especially sensitive. In the 
present case, a period of somewhat less than six weeks had 
sufficed to produce secondary degenerations above and be- 
low the fifth dorsal segment, of a quite classical sort. 

Accordingly, we here deal with a severe form of spinal con- 
cussion due to a shellburst, in which intraspinal lesions were 
produced without spinal fracture or penetration either of bone 
or of shell fragments into the spinal cord or the spinal fluid. 



274 shell-shock: nature and causes 






Shell explosion (i meter distant) kills a soldier by 
bursting both lungs within the intact thoracic cage. 



Case 201. (Sencert, January, 1915.) 

A man of the 26th Regiment of Infantry was brought 
October 26, 1914, to Ambulance No. 6 of the Twentieth Army 
Corps at the Chateau d'Henu. Weakly and jerkily the man 
was able to tell how, as he was going forward, a large calibre 
shell fell less than a meter in front of him and exploded. He 
fell back and lost consciousness, was picked up in the evening 
and carried to the relief post and then to the ambulance, where 
he arrived ten hours after the fall. There were signs of a con- 
siderable shakeup, with pale and anxious face, nose pinched, 
hollow eyes, rapid superficial respiration, small pulse, 120, and 
a feeble voice. There were small skin wounds of the right 
arm, a finger, and ear, but there was otherwise no^wound. 
The thorax and abdomen were somewhat painful all over, but 
there was no especial point of pain. The chest showed a 
slight dulness at the bases. Examination of the abdomen 
produced defensive movements and the man vomited blood 
during examination. He was put on his back, kept warm, 
given artificial serum, hypodermic injections of camphorated 
oil and caffeine, and carefully watched. In the night he 
had another bloody vomiting, his pulse became smaller and 
smaller, dyspnea became more and more intense, and he died 
late in the night. 

The autopsy showed that the abdomen was free of lesions 
and that all the organs were of a normal appearance and color. 
There was no sign of perforation or of peritonitis. The 
stomach itself was filled with blood and there was a generalized 
ecchymotic appearance of the mucosa, with mall, submucous 
hematomata and a number of tears in the pyloric portion. 

The pleurae were found filled with blood, almost a quart 
in each cavity. The right lung showed a large tear at the 
level of the middle lobe, 15 cm. long. An orange-size, black 
bit of lung protruded through the tear. There was no sign of 
rib fracture opposite this tear, and no subpleural, intercostal 



shell-shock: nature and causes 275 

or subcutaneous contusion. The thorax wall was perfectly 
normal. 

The left lung showed, in the middle portion of the upper 
lobe, a somewhat analogous pleural tear, almost as big as that 
on the right, with another large hernia of black lung. Bits 
of the herniated lung sank in water. The thorax wall was 
intact. The pericardium was free from blood. There was 
nothing else abnormal about the body. 

Re effects of an explosion upon structures with intervening 
objects left intact, Fauntleroy notes that a shell bursting 
three yards from an aneroid barometer may force its levers 
into an abnormal position. A further fact will indicate how 
permanent is the physical state into which the levers are 
forced; for when the barometer with its levers placed right 
was placed under a bell- jar and the pressure therein was 
reduced to 410 mm., the levers resumed the position into 
which the explosion of the big shell had thrown them. 

Re windage and internal effects in the human body, Ra- 
vaut recalls the fact that the internal and intraneural hem- 
orrhages of Caisson disease ("bends") are well known. The 
external hemorrhages of aeronauts and mountain climbers 
belong in the same physical class. Dynamite exploded in a 
pond kills fish. Dynamite may break pillars inside a build- 
ing without damaging its front. Cases like Chavigny's (198), 
Roussy and Boisseau's (199), Claude and Lhermitte's (200), 
as well as Ravaut's own case (202) are in point. 






276 shell-shock: nature and causes 



Shell explosion near by : Paraplegia, interpreted as 
due to windage. Two foci of HEMORRHAGE 
(SPINAL CANAL, BLADDER) clinically proved to 
exist in a case without external sign of injury. 



Case 202. (Ravaut, February, 191 5.) 

An infantry sergeant was brought to the ambulance, one 
day in November, 19 14, with a paralysis which had set in 
immediately upon the explosion of a large shell a short dis- 
tance away. Both legs were paralyzed and there was an- 
esthesia to the navel. He could not urinate. It was early 
in the war, and Ravaut thought he would find an injury to 
the vertebral column, but on undressing the soldier there 
was no wound. The skin was intact, and there was not even 
an ecchymosis. The patient was suffering not at all, but 
said that after the shell exploded he felt a forcible shock, 
was stunned for a moment, and when he wanted to rise, found 
that his legs were inert. His state did not change during the 
day and he did not urinate. Catheterization showed a 
urine full of blood. This indicated a lumbar puncture, and a 
bloody fluid emerged under great pressure. Thus two foci 
of hemorrhage were proven to exist in this patient despite 
the fact that there was no external lesion. 

Re windage effects, see suggestions of Ravaut under Case 
201. Ravaut also suggests that certain cases of emotional 
jaundice may be similarly explained on the basis of internal 
lesion due to windage. Sundry cases of gastro-intestinal 
disorder and of hemoptysis fall into the same class; possibly 
the cases of death in a fixed posture belong there, too. 
Ravaut thinks, despite the look of hysteria about the shell- 
shock cases of paraplegia, deafness, mutism, and the like, 
that the cases are actually ones in which there has been at 
the beginning a slight or severe hemorrhage, clearing up in 
a few days. He states that there is a pretty definite paral- 
lelism between the course of the clinical symptoms and the 
chemical characteristics of the spinal fluid. 



shell-shock:: nature and causes 277 



Shell-explosion in confined space; paraplegia after 
fifteen minutes; slight hemorrhage and LYM- 
PHOCYTOSIS of spinal fluid; Hematomyelia. 



Case 203. (Froment, July, 1915.) 

A Sergeant lying down in a small dugout space, 2 X 1 m. 
high, had a yy shell burst behind his head and between his 
head and the back of the dugout. The patient was not 
moved by the explosion, but was buried in a small amount 
of earth and stones to a depth of about 20 cm. He was not 
wounded and showed no ecchymoses either then or later. 
Aided by stretcher bearers, he was able to walk to the relief 
post about 400 meters from the trench. He did not lose 
consciousness, and got to the relief post about a quarter 
of an hour after the shell burst. Thereafter, however, he 
was unable to move his legs. The accident happened 
February 6 at 4 o'clock. He was examined 24 hours after 
the trauma. The accompanying diagrams show the vari- 
ations in sensory disorder at intervals during six months. 

A lumbar puncture, February 8, 191 5, showed hypertensive 
clear fluid without macroscopic clot on centrifuging, but 
showing a number of red blood cells and lymphocytes — 
3 or 4 to the microscopic field. There was a slight hyperal- 
buminosis. The development of the muscular atrophy and 
hypo-excitability of the left lower extremity, the exaggera- 
tion of the left knee-jerk, together with the spinal fluid 
appearances, seemed to prove the organic nature of the para- 
plegia. There was an intense rhachialgia, with radiation 
along the sciatic nerve. This outlasted all other symptoms. 
Thermo-analgesia was the most prominent sensory disorder. 
There were no sphincter disorders. 

During the first days, the anesthesia was of a pure seg- 
mentary type, with nothing about it to suggest that it was 
later to be supplanted by a radicular type of disorder. Hema- 
tomyelia was, years ago, thought — according to Froment — 
to tend to yield sensory disorders of a segmentary nature. 
At the outset this anesthesia was total, though there was a 



278 SHELL-SHOCK: NATURE AND CAUSES 

vague, poorly localized feeling on intense painful excitations, 
— as with energetic pricking or burning. Thus the proto- 
pathic sensibility of Head had remained, whereas the epi- 
critic sensibility had disappeared. 

Detailed examination of this case showed extreme errors 
in the position sense. For example, pricking the foot might 
be localized as pinching above the knee. The cremaster 
reflex was extremely marked and would appear upon even 
slight excitation of any part of the lower extremity, even at 
times when the patient declared he felt nothing. These 
phenomena at the beginning early gave place to a syringo- 
myelic type of anesthesia. 

At the time of report, July 29, 1915, Froment regarded this 
case as analogous to hematomyelias of divers, although there 
is not such a degree of decompression; the suddenness of 
the decompression is more marked in these Shell-shock cases 
than in divers. 



shell-shock: nature and causes 279 



Shell explosion; bowled over; loss of conscious- 
ness: Hemiplegia with reflex signs thought to be 
organic; hypertensive spinal fluid; LYMPHOCY- 
TOSIS. 



Case 204. (Guillain, August, 1915.) 

A corporal in the engineers was going the night of June 
7th to a creneau of mitrailleuses, when he was bowled over 
by a bursting shell. He lost consciousness and was carried 
to the cantonment by his comrades. Next morning he com- 
plained of headache and pain in the back ; had a convulsion ; 
and proved on examination to have a left-sided hemiplegia. 
He was given the diagnosis of hysterical hemiplegia. 

He was sent to the 6th Army neurological center, and there 
showed a complete left-sided hemiplegia with tendency to 
contracture. The left knee-jerk and arm reflexes were 
exaggerated, and there was ankle and patella clonus with 
Babinski sign. There was a dysesthesia on the left side, 
with wrong interpretation and poor localization of painful 
stimuli, and non-recognition of cold and heat sensations. 
Muscle sense and stereognosis were impaired. There was a 
slight dysarthria. Lumbar puncture yielded a clear hyper- 
tensive fluid with a slight lymphocytosis. 

The situation remained without change for a month, when 
the patient was evacuated to the rear. Thus, a shell-burst 
can produce destructive nerve lesions without evidence of 
external injury. 

Re hypertensive spinal fluid, Sollier and Chartier cite De- 
jerine as having brought the proof of hypertension in the 
cerebrospinal fluid in Shell-shock cases. They also believe 
that the Shell-shock hysteria is built up on a physical basis, 
more or less after the model of Charcot's hysterotrauma- 
tism. Shock, windage, and gas may bring about the same 
kind of result. They rely especially on the cases of Sen- 
cert (201) and Ravaut (202) for their argument (191 5). 
They recall the fact that Charcot found a hysteria due to 
lightning stroke and to high tension electric accidents. They 
quote Lermoyez as attributing like results in ear cases to 
labyrinthine shock, tympanic rupture, and ear hemorrhages. 



280 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock : Hemiparesis, amnesia. Lumbar punc- 
tures early (but here as late as one month after 
shock and after disappearance of hemiparesis) 
showed PLEOCYTOSIS and hyperalbuminosis. 



Case 205. (Souques, Megevand and Donnet, October, 

1915.) 

A French sergeant, a machine gunner, was the victim of 
shell-burst September 25, 191 5, was evacuated with a diag- 
nosis of commotio cerebri, and, when examined at Paul- 
Brousse October 5, showed a right-sided hemiparesis, clouding 
of consciousness and somnolence, the hemiparesis involving 
the face, with deviation of tongue to right, Babinski reflex 
right, cremasteric and abdominal reflexes abolished on right. 
Normal respiration and pulse. 

Lumbar puncture October 7, that is, thirteen days after 
the injury, yielded a clear fluid with an excess of albumin, 
144 small lymphocytes (some degenerate) and a single en- 
dothelial cell. 

October 12, the knee-jerk was a little less lively on the 
right side. The plantar reflex varied between extension and 
flexion on the right side. The cremasteric reflex had been 
weakly regained on the right side. 

The patient was now less stupid and could tell how he 
jumped when the shell burst, and how he had been in the air 
ten minutes (!) and fell, getting up at once, with nothing 
wrong except nosebleed. After a half -hour he felt weaker 
and was ordered to leave the post, whereupon, on the road, 
his weakness increased and he tended to fall to the right, but 
reached the ambulance on foot. 

October 23, there was no longer any evidence of hemiparesis, 
the Babinski reflex had entirely disappeared; there was no 
complaint except of dizziness and headaches. He got back 
his autocritique on the matter of remaining in the air ten 
minutes, but there was still an amnesia for the ten day period 
between the shock and his arrival at Paul-Brousse. He 
forgot that he had had a lumbar puncture October 7. 



SHELL-SHOCK: NATURE AND CAUSES 28 1 

Another puncture, October 25, yielded some 14 or 15 
lymphocytes to the cmm. There was still an excess of al- 
bumin. The lymphocytes decreased further according to a 
puncture November 2. Had this patient been examined 
some weeks after the shock there would have been no signs 
of an organic paresis, no special modification of the spinal 
fluid, and no reason for regarding the man as other than an 
hysteric. Early spinal puncture is, accordingly, important. 

Of course, the question whether the lymphocytes and hyper- 
albuminosis of the fluid might not be syphilitic must be raised. 
At the Hospital Medical Society meeting, October 29, 19 15, 
Souques states that Ravaut and Guillain believe that simple 
shell-shock often produces " syphilitic " chemical, physical 
or cytological changes in the spinal fluid. Roussy is cited 
as thinking such changes rare. 



282 SHELL-SHOCK: NATURE AND CAUSES 






Shell-shock ; burial : Coma and semicoma ; BLOOD- 
STAINED SPINAL FLUID. Improvement on 
puncture. Persistent astasia abasia with spasticity. 



Case 206. (Leriche, September, 191 5.) 

A man was buried March 15, 191 5, following the burst- 
ing of a large calibre shell. He is said to have had hemopty- 
sis and arrived at hospital March 17 in coma. He kept 
moaning while asleep. March 18, he was still stupid and 
as if stunned. He did not talk or understand what was 
said, but was able to write a few words. The knee-jerks were 
a little exaggerated. There was a slight spasticity of the 
limbs, which was exaggerated on emotion into a sort of 
spasmodic crisis. 

Lumbar puncture gave a reddish fluid under strong ten- 
sion. After lumbar puncture the man came out of coma and 
the next day, after another puncture (fluid slightly yellow- 
ish), there was further improvement and the patient spoke. 
The third puncture, March 20, yielded yellow fluid. The 
spastic phenomena still persisted, however. The patient 
could not walk or stand. Every time he touched the ground 
he had a clonic crisis. He was evacuated to a neurological 
center. 

Re astasia-abasia, Nonne found these cases heading a 
group of 63 cases of war hysteria treated in a twelvemonth. 
Figures as follows: 

Astasia-abasia 14 

Generalized tremor 12 

Brachial monoplegia 11 

Isolated contracture 6 

Crural paraplegia 5 

Mutism 5 

Isolated tic 4 

Hemiplegia 3 

Isolated respiratory convulsions 2 

Isolated sensory disorder 1 

Fifty-one of the 63 cases were freed by therapy from their 
main symptoms (twenty-eight cases cured in one or two 
hypnotic sittings). 



SHELL-SHOCK: NATURE AND CAUSES 283 



Prolonged bombardment; shell explosion (near- 
by?): Depression; suicidal attempt; hypertensive 
spinal fluid. 



Case 207. (Leriche, September, 1915.) 

A patient entered an evacuation hospital June 27, having 
come from an ambulance with a ticket reading, " Melancholic 
depression, with stupor — attempt at suicide (threw himself 
into a pond) — sprained ankle — to be evacuated, lying 
down, on a milk diet." The patient was depressed, indiffer- 
ent to surroundings, irresponsive, and did not even look at an 
interlocutor. There was no other somatic sign except a 
pulse of 62. He did not eat, and remained lying down, with- 
out movement. Lumbar puncture in a sitting posture yielded 
a clear liquid under pressure of 34. June 30, another lumbar 
puncture yielded clear fluid of a dichroic appearance when 
looked at from above. 25 c.c. were removed. July 1, there 
had been a good deal of improvement. The patient said he 
was better and began to take a little milk. July 2, there was 
still some improvement. Pulse 60. He said that his con- 
dition had lasted a month and that it followed a violent and 
prolonged bombardment for ten days in his sector. July 
3, he was much better, began to look about, talk, and eat a 
little. July 4, lumbar puncture yielded a clear fluid with a 
pressure of 30, reduced to 22 after withdrawal of 20 c.c. 

According to Leriche, explosion of large calibre shells or 
of a mine can produce cerebral or spinal symptoms, some of 
which are removed by lumbar puncture. The fluid is red 
shortly after the explosion and under hypertension for some 
days. Such hypertension may be found even in shell cases 
that have no other sign of cerebral condition. This par- 
ticular melancholy patient had a relapse and another de- 
pression with fugue. 



284 shell-shock: nature and causes 



Example of HEMATOMYELIA, indirect result of 
bullet wound. Partial recovery. 



Case 208. (Mendelssohn, January, 191 6.) 

An infantry subaltern, 23 years old, was injured September 
24, 1 9 14, by a rifle bullet, which entered above the left 
clavicle and emerged between the right scapula and the ver- 
tebral column. The patient leaped into the air when he was 
struck, but fell at once and found that his legs were paralyzed. 
A feeling of cold crept up from the feet to the region of the 
umbilicus. Consciousness was preserved. There was hem- 
optysis because of the bullet's passing through the left lung. 
The wounds all healed quickly. There was retention, fol- 
lowed by incontinence, of urine and feces; and the situation 
was complicated by eschars in the gluteal and trochanteric 
region. 

For three months there was no change in the paraplegia, 
except that at the beginning of the third month the patient 
could move his fingers a little and raise his knees slightly. He 
was transferred back through three hospital units, with a 
diagnosis of spinal cord lesion or fracture due to a vertebral 
column lesion at the second and third dorsal vertebrae. 

Seven months after injury, he reached a Russian hospital 
for a laminectomy, incapable of standing or walking without 
support, although able to sit and rise with extreme difficulty. 
He could now very slightly flex and extend the knees, and 
very slightly flex and rotate the ankle, and weakly move the 
toes. Passive movements could be carried out without much 
difficulty, though there was a slight joint and muscle stiffness. 
Both quadriceps muscles were markedly atrophied. There 
was slight amyotrophy of the lower legs. Tendon reflexes 
were exaggerated, and there was a marked ankle clonus, a 
Babinski reflex, and an abolition of the abdominal and cre- 
masteric reflexes. 

There was a sensory disorder of an incomplete syringo- 
myelic pattern, with diminished sensibility to heat and 
complete abolition of pain sensibility. Touch and electric 






shell-shock: nature and causes 2S5 

sensations were somewhat delayed. There was a diminution 
in the faradic and galvanic excitability of the legs and feet; 
vasomotor disturbance (slight hyperidrosis) of the paralyzed 
limbs. Two of the eschars had not yet cicatrized. The 
sphincteric disturbances had diminished. For the rest the 
patient was normal. The second and third vertebrae showed 
deformity and were painful to pressure and percussion of 
spinous processes. 

The patient was treated by galvanization of the spine, with 
a current descending at first and then ascending, and by 
faradization of the paralyzed muscles. There was progres- 
sive improvement, irregular but constant. At the time of 
report, July 1, 191 5, he was perfectly well, able to take long 
walks, and without sphincter or sensory disturbance. The 
tendon reflexes were still exaggerated, and there was still a 
slight ankle clonus and Babinski. The abdominal and cre- 
masteric reflexes were still abolished. The last of the seven 
eschars had not yet healed over. 

For the organic nature of this lesion, the numerous early 
eschars, the persistent sphincter disturbances, the limited 
paresis of the legs, the reflex disorders, and the dissociation 
of sensations seem abundant evidence. It is probable that 
there was no fracture of the vertebrae (X-ray confirmation), 
and it is probable that there was a meningeal hemorrhage, 
together with some hemorrhagic foci in the spinal cord sub- 
stance, especially in the gray matter. A good deal remains 
doubtful : Mendelssohn remarks that the sphincter disturb- 
ances ought to be related to disorder of the fourth and fifth 
sacral segments, and the knee-jerk and Achilles jerk absence 
with disorder of the lower lumbar, and sacral region; the 
abdominal reflex disorder with the low thoracic lesion; the 
distribution of the anesthesia ought to indicate a lesion in 
the lower part of the spinal cord. Was not the hemorrhage 
therefore lower down than the spot where the vertebrae were 
displaced? It is surely of prognostic note that the eschars 
did not necessarily foretell a fatal outcome; in fact, the 
patient had become functionally well before the seventh 
eschar was healed over. 



286 SHELL-SHOCK: NATURE AND CAUSES 



Shell explosion with subject lying down applied to 
machine-gun; no contusion: HEMATOMYELIA. 
Partial recovery. 



Case 209. (Babinski, June, 191 5.) 

A veterinary student, six months captive in Germany, 
wrote out for Babinski the following: 

"September 1, 1914, I was about to operate a ma- 
chine gun when a shrapnel shell exploded very near me, 

— probably about two or three metres overhead. I 
base this estimate on comparisons made with shells I 
saw exploded beside me before this one. 

"Just after the explosion, which deafened me and at 
the same time took my breath away a little, from the 
powder, I felt a rather severe pain in the kidney region, 

— a pain which then persisted without interruption. 
I moved my left arm, to find the effect produced by a 
bullet which I heard whistle by my ear and which 
struck the upper part of the left shoulder without 
entering. At the same time, I tried to turn to see 
what had become of my legs, and had a feeling that 
they had vanished. Almost immediately I felt little 
prickings, not very painful, in the lumbar region and 
in the upper part of the thighs. Just then, seeing my 
comrades going away I tried to imitate them, but could 
not. All these feelings passed very rapidly. 

"A comrade then came near to tell me to go back. 
I told him that I could not move and that I must have 
been wounded in the lumbar region. He looked at my 
kit and my coat and said there was no trace of shot or 
tear. Not wanting to leave me, he lifted me by the 
armpits and knees. I could not help him get me up, 
and my legs hung flexed and inert. After a few steps 
he had to put me down, and tried to stand me up. I 
immediately crumpled. I had no sensation of my feet 
touching the ground. I sent my comrade back, asking 
him to tell my brother, who was in my squad. I did 
not lose consciousness or any feeling of my situation, or 
of the danger being run by my comrade." 

The man remained four days on the battle field without 
food. He was on the edge of a stream. He did not defecate, 
nor for two days did he urinate. Eventually the bladder and 



SHELL-SHOCK: NATURE AND CAUSES 287 

rectal functions were re-established, though they remained 
irregular. Catheterization was never resorted to. The lum- 
bar pains were diffuse, fixing themselves a few days after the 
accident in the region below the umbilicus. There were 
pains at the waist predominating on the left side. The 
paralysis of the lower extremities grew rapidly better. 
Movements in the right leg reappeared, and 27 days after the 
accident the man was able to stand and walk around his bed. 
Still further movement followed (left leg weaker) . 

At the time of the report, May 28, 1915, the patient could 
walk without a cane, but he could get about only slowly. 
The left toes would rub against the ground, and he could not 
support himself for any length of time on his legs. The 
knee-jerks were exaggerated, especially the left. The 
Achilles jerks were increased. There was a Babinski reflex 
on the left side and an abduction of the fifth toe on plantar 
stimulation. The same reflexes were found on the right side, 
but less marked. Abdominal reflexes absent, except the 
right superior reflex, which was distinctly present. Cremas- 
teric reflexes absent. Anal reflexes preserved. The defense 
reflexes were exaggerated, but more markedly on the left 
side. The zone from which the defense reflexes could be 
elicited on the left side included the whole lower extremity 
and rose as far as 2 or 3 cm. above the nipple. Stimulation 
of the lateral parts of the left lower extremity would even 
produce defense reflex movements on both sides of the body. 
On the right side, however, the defense reflex movements 
could only be tried out by scratching the anterior surface of 
the ankle, which was then followed by a flexion of the foot. 

Sensibility to touch and deep sensibility were preserved; 
but sensibility to temperature and pain, normal on the left, 
— i.e., paralyzed — side, was weak in the right leg. There 
was a marked sudation on the left side, limited by the white 
line, the inguinal fold, the iliac spines, and a horizontal line 
passing through the umbilicus. 

Here, then, paralysis followed a shell explosion while the 
subject was lying down. No contusion therefore was pos- 
sible. According to Babinski, we are dealing probably with 
a hematomyelia, the result of shell explosion. 



288 shell-shock: nature and causes 



Struck by missile in back; unconsciousness; no 
wound : Hysterical paraplegia? HERPES and SEG- 
MENTARY HYPERALGESIA suggest radicular 
and spinal injury. Recovery. 



Case 210. (Elliot, December, 1914.) 

November 1, 19 14, a sergeant in the 20th Hussars, with 
other dismounted cavalrymen, was chasing Germans with 
a bayonet, over turnip fields pitted by shells. Several hours 
later, he found himself in a house in a nearby village, to 
which he had been carried unconscious. Probably he had 
been struck by some missile in the back, as the bottom of his 
haversack had been torn off. His face was blackened with 
smoke, and his clothes were muddy. He had no wound. 
His left arm was weak and his legs powerless and numb. 
The passing of water was painful, but there was no blood in 
the water and no hemoptysis. 

Five days later, he was examined at a base hospital and 
found to be paralyzed and numb in the legs. The knee-jerk 
and ankle- jerk were retained upon the right side only. Pain 
occurred on passive movements of the legs, which were 
flaccid; there was a hyperalgesia about Poupart's ligament, 
more marked on the left side. Lower abdominal reflexes 
were weak on the left side; pain in lower abdomen with 
bladder full and at outset of micturition. Pain and paresis 
also affected the left arm, but there was no numbness. Pain 
on pressure over lumbar and cervical vertebral spines. 
There was no evidence of bruising. 

The physicians were inclined to regard tne phenomena as 
hysterical. Three days later, the arm movements became 
much freer, and after another three days, the arm move- 
ments were fairly powerful, and the legs much stronger, al- 
though the patient could not yet stand or walk. He still 
had pain if his bladder was full. 

As against the diagnosis of hysteria, three herpetic clusters 
appeared on the skin of the left thigh, from three to six inches 
above the knee. Elliot regards it as certain that the pos- 



SHELL-SHOCK: NATURE AND CAUSES 289 

1 



CAUSES OF SHELL-SHOCK 



HEAD INJURY 
ATMOSPHERIC CONCUSSION 
MENTAL STRAIN 
NON-NERVOUS TRAUMA 

ta#& j; ■»■;-. ■ #+'■<&&*■•: ■ W»: ■&?■. ■ . -1 

NEUROPATHIC HEREDITY 



After Ballard 



Chart 9 



290 SHELL-SHOCK: NATURE AND CAUSES 

terior root ganglia were injured. He regards the case as 
one of injury to the spinal nerve roots. The hyperalgesia 
about the body of course suggested damage to the spinal 
cord. According to Elliot, therefore, this case is one of 
organic disease; whether of the roots or of the cord was un- 
certain. At any rate the cases of this type, though not 
functional, recovered. 



shell-shock: nature and causes 291 



Mine-explosion; burial; labyrinthine lesions and 
head bruises, more marked on left side: Focal 
canities (WHITE HAIR developing OVERNIGHT) 
on left side. 






Case 211. (Lebar, June, 1915.) 

A soldier, 23, in the Argonne was blown up by a mine in 
a trench, fell, and was covered by a mass of earth, from 
which he extricated himself. He immediately became deaf 
from what was medically determined to be a double hem- 
orrhagic labyrinthitis. There were also superficial powder 
burns of the face, as well as several bruises on the head, 
especially on the left side. 

The next day, at the English hospital at Arc-en- Barrois, 
the patient noticed tufts of white hair on the left side of the 
head. There were four islets of gray hair in the left fronto- 
parieto-occipital region, separated from one another by nor- 
mal hairs. The gray hairs were gray completely from the 
roots to the ends of the hair. The longest hairs were as 
white as the shortest. There was not a brown hair amongst 
them. The gray hairs were solidly implanted, and could 
be pulled out only by strong traction. There was a dis- 
coloration also of the bulbar swelling of the hair. The rest 
of the head hair was dark brown. His hair was described 
in the military description: " deep chestnut brown." There 
was no other symptom aside from an incessant twitching of 
the left eyelids. The place of whitening was apparently 
determined by the region of the scalp injured. Not only 
were the bruises on the left side of the head and face, but 
the labyrinthine lesions were more marked on this side and 
the twitching of the eye-lids was confined to the left side. 



292 SHELL-SHOCK: NATURE AND CAUSES 



Shrapnel wound of skull ; focal canities over wound ; 
shell-shock and shrapnel wound of right leg. Head 
tremors and contractions, changing in relation to 
posture; glove anesthesia and local anesthesia of 
trunk. 



Case 212. (Arinstein, September, 191 5.) 

A Russian private, 24, was wounded twice: once in the 
head by a bullet, and at another time by a bit of shrapnel 
that imbedded itself in the skull. The hair over the injured 
spot became gray. 

Later, September 16, 191 5, the soldier was subjected to 
shell-shock, and at the same time wounded by shrapnel frag- 
ment in the right leg (operated next day). 

Upon examination at Petrograd, the hearing was found 
diminished and the eardrum was pulled in. At first the 
patient could not speak or open his eyes, and made incessant 
lateral movements of the head, jerking backwards and to the 
right. The right half of the face gave convulsive move- 
ments, which began at the lip and spread upwards. Dur- 
ing sleep, there was an entire cessation of these head shakings 
and jerks. In the lying posture, the head shook at a rate of 
100 to 120 per minute. The jerking movements became 
more marked when the patient sat up or walked. He carried 
his head bent toward the right shoulder. When he sat down, 
the side-shaking movements disappeared, only to reappear 
when he lay down. The swallowing reflexes were absent. 
The sensitiveness to touch, pain, and temperature was lost 
in the upper part of the trunk including the neck, to the level 
of the tenth dorsal vertebra. There was anesthesia of the 
arms as far as the elbow on the right, and as far as the 
shoulder on the left. The mucosae of the mouth were an- 
esthetic. Dermatographia was strongly marked. 



shell-shock: nature and causes 293 



Shell explosion; burial: Hemiplegia, probably 
organic. 






Case 213. (Marie and Levy, January, 191 7.) 

A soldier was blown up by a shell and then buried at Vaux, 
March 29, 1916, and entered the Salpetriere, July, 1916, with 
a right-sided hemiplegia and contracture without evidence of 
wound. He remembered nothing for the first fortnight after 
the trauma. When he came to himself, he was paralyzed 
and was unable to say more than a few words, but at the 
end of a month his aphasia ceased and he began to walk. 

The hemiplegia was spastic. There was pronounced 
contracture. The arm was extended, hand open, fingers 
stretched. Finger movements were diminished, as well as 
extension of the wrist, but the arm was otherwise normal. 
The leg was not so stiff. The great toe was in a state of con- 
tinuous extension. The toes could not be moved, and the 
foot scarcely; but the leg could be strongly flexed and ex- 
tended on the thigh. The tendon reflexes of the right side 
were more lively than on the left. Cloniform movements 
followed tapping the patellar tendon on the right side, and a 
patellar clonus and ankle clonus could also be demonstrated. 
Plantar reflex, flexor on the right. Distinct adduction of the 
foot. Slight disturbance of tactile sensibility in the para- 
lyzed limbs; marked disorder of position sense and gross 
disturbance of stereognostic sense. Moderate dysarthria. 

Ten months after the traumatism, the hemiplegia and 
spastic walk remained. The upper limb was now carried in 
extension back of the body, with hand supinated, fingers 
sometimes in extension, sometimes in flexion, index finger 
separately from the others. Finger movements difficult and 
shoulder movements limited. The leg, however, was almost 
normal except that the toes could not be moved. The tendon 
reflexes were more lively and cloniform on the right, but 
there was no longer patellar or ankle clonus. Stereognosis 
slow, but finger movements were naturally difficult. W. R. 
of blood, negative. Probably this is an organic case. 



294 SHELL-SHOCK: NATURE AND CAUSES 



Blown up by a shell; no skin or bone lesion: 
Mixture of organic (e.g., lost knee-jerks) and func- 
tional (e.g., urinary retention) disorders. 



Case 214. (Claude and Lhermitte, October, 1915.) 

A man, 38, was blown up in a trench without sustaining 
skin or skeletal lesions, April 5, 191 5. He lost consciousness 
for a half hour and, coming to, found a crural paraplegia 
and urinary retention. Examined July 24, in addition to the 
paraplegia were found tactile and algesic hypesthesia of the 
legs with preservation of deep sensibility. Pains were felt 
in the legs, especially in the hips. The knee-jerks were 
abolished; the Achilles jerks were preserved, as well as the 
flexor plantar reflexes and somewhat weakened cremasteric 
and abdominal reflexes. Micturition was difficult. Con- 
stipation. Slight paresis of left arm. Lumbar puncture, 
July 28, yielded a clear fluid of normal tension without 
chemical or cytological changes. 

The sphincter disorders gradually disappeared. The knee- 
jerks reappeared in a weakened form August 31. The legs 
could, at the time of report, be moved somewhat, though not 
above the level of the bed. 

We here deal, presumably, with a mild form of concussion 
of the spinal cord, in which, however, some of the transient 
symptoms are very possibly merely functional in origin. 

Re complicated pictures of organic and functional nature, 
some experimental work has been carried out. Mairet and 
Durante set off explosives, such as melinite, at a distance of 
1 to 1.5 metres, near rabbits. Some died at intervals from 
an hour to thirteen days; others lived. Pulmonary apo- 
plexy was found in the cases dying early. Spinal cord and 
root hemorrhages, hemorrhages in the cortical and bulbar 
gray, perivascular and ependymal hemorrhages were found, 
always small and without diffusion, suggesting rupture by 
rapid decompression following the first wave of aerial com- 
pression. The functional effects are thought to be brought 
about through the anemia of the areas supplied by the rup- 



SHELL-SHOCK: NATURE AND CAUSES 



295 



tured vessels. Russca of Berne got similar results and notes 
direct and contrecoup brain lesions, tympanic perforations, 
intra- and extra-ocular hemorrhages, thoracic, cardiac, and 
splenic hemorrhages, ruptures of kidney, stomach, intestine, 
and diaphragm. As in the work of Mairet and Durante, 
the lung proved the most sensitive organ. (Compare also 
the human case of Sencert [Case 201].) Some experiments 
with fishes yielded lesions of the swimming bladder. Per- 
salite and other explosives were used. 









»96 SHELL-SHOCK: NATURE AND CAUSES 






GASSING : Organic-looking picture. 



Case 215. (Neiding, May, 1917.) 

A German soldier, 21, was a serious case of gassing. He 
was unconscious two days (venesection twice). When he 
came to, he could not walk and felt as if he were drunk. 
October 22, 19 16, he was incoordinate in walking and tended 
to fall forward when standing with eyes closed. The ataxia 
of the legs was demonstrable in the position of dorsal de- 
cubitus, and there was also a slight ataxia of the arms. The 
pupils were dilated and reacted poorly to light. 

December 12, all symptoms had disappeared. The clinical 
picture in this case was somewhat like that of a multiple 
sclerosis. According to Neiding, the disorder is not a func- 
tional one but an organic cerebellar disorder. 

Re the neurology of gas poisoning, Neiding regards the 
condition as a new nosological unit. We do not know 
what the ultimate results of apparently cured cases will be. 
Court questions of importance will doubtless arise with ref- 
erence to their compensation. Ninety-six of Neiding's 274 
cases failed to show any nerve symptoms whatever; forty- 
six cases showed one symptom only, such as headache, diz- 
ziness, abnormality of reflexes, or abnormality in sensation. 
One hundred and thirty-two cases presented a fairly full 
picture. The picture of a complete traumatic neurosis not 
infrequently appears, aided perhaps by the psychic features 
of the gas attacks; and possibly some cases are entirely 
psychogenic from the beginning. Such symptoms, for ex- 
ample, as dermatographia, rapid and irregular heart, hyperid- 
rosis, blepharospasm, mental perturbation, hypochondria, 
etc., do not necessarily point to any directly toxic effect 
of the gases. Thirty-seven of Neiding's cases showed 
pupillary changes, hyperreflexia, and analgesia. Thirty-one 
showed analgesia and absence of laryngeal and corneal re- 
flexes. Twenty-six showed pupillary changes and hyperre- 
flexia, four of these latter showing also an absence of laryngeal 
and corneal reflexes. One case yielded hyperalgesia alone; 
ten yielded headache, dizziness, and analgesia. 



SHELL-SHOCK: NATURE AND CAUSES 297 



GASSING: Mutism, tremors, depression, battle 
dreams. 



Case 216. (Wiltshire, June, 1916.) 

An infantryman, aged 27, had been at the front for three 
months. He was wounded a month before coming to hos- 
pital ; but when the wound healed he went back to the front, 
quite mute but intelligent and able to write the following: 

"We were on our way to the trenches, and as we 
were going through the railway cutting they started to 
shell us, with gas shells mostly, and we had not been 
there more than quarter of an hour when I was com- 
pelled to lie down from temporary blindness and weak- 
ness through getting a dose of gas through my mouth 
and eyes. I was lying down for about ten minutes 
when a shell came somewhere near, and was struck by 
something in the face and on my left knee and I re- 
membered no more until I found myself in hospital. 
I was all of a shake and while lying down would fre- 
quently jump up and wonder where I was." 

The patient had been mute thereafter, depressed, and 
given to dreams about fighting and shells. There was a fine 
tremor controllable by the will; the knee-jerks were in- 
creased. On lateral deviation, there was difficulty in fixing 
the eyes. There was a slight deafness due to an old dis- 
charging left ear. According to Wiltshire, Shell-shock is only 
exceptionally caused by chemical poisoning from gas. 

Re poisoning by certain German asphyxiating gases, 
Sereysky reports in 191 7 that these gases contained, among 
other poisons, a nerve poison. He found that poor heredity 
was a favorable soil for the action of this nerve poison. The 
clinical pictures in the gassed soldiers rather suggested cere- 
bral arteriosclerosis. He remarks that the logical distance 
between the " exogenous " and "endogenous" is greatly 
reduced in these gassed cases, as the syndrome of "exog- 
enous" gassing closely approximates that of various "endog- 



298 shell-shock: nature and causes 



Hysterical speech disorder related to mechanical 
disorder of auditory apparatus. 



Case 217. (Binswanger, July, 1915.) 

Whenever a German officer's servant, 23 years, was ad- 
dressed on the ward in the Jena Nerve Hospital, his hands 
would tremble and the muscles of his face would fall into 
grimacing associated movements. He had a peculiar infan- 
tile type of speech, talking with a fixed glance and an anxious 
mien. He would carefully utter, as a rule, separate words, 
chiefly only nouns or infinitives. He would gesticulate with 
both hands to make what he said understood. Thus (freely 
translating the German) runs his description of a battle : 

"Well — because — I — we had — no artillery and so 
many losses — then got in position again, then we — laid 
down a long time — perhaps until four o'clock in the after- 
noon — five — and — and it happened that — lay in Riiben- 
feld — couldn't go back — then shell near me — fell in and I 
right near, how — how far — I don't know and — grown 
better. Comrade said — 10 meters — don't know — un — 



unconscious." 



Long compound German words could not be repeated, 
since after the first or second syllable there was a severe emo- 
tional excitement ; syllable articulation and phonation ceased. 
Finally, however, the patient could be gotten to pronounce the 
whole word. Reading aloud was very difficult : syllable sound- 
ing and omission of difficult syllables ; after a time, weeping. 

The patient was a somewhat small, muscular, well-nour- 
ished man, with a murmur at the apex, a somewhat rapid 
pulse, increased reflexes, especially skin reflexes, painful 
supra- and infra-orbital points, temples painful to percussion, 
pressure over spine painful from second thoracic to third 
lumbar vertebrae. There was an increased sensitiveness to 
touch and pain over the whole body. There was a bilateral, 
somewhat marked tremor, more marked on the left side than 
on the right. Swaying in Romberg position was slight. 
Tremor of tongue. 



shell-shock: nature and causes 299 

This patient was first brought to Jena November 23, 1914. 
An illegitimate child, a moderately good scholar, he had 
worked as a mason until he went into the army, in 191 2. He 
worked as a soldier chiefly in the officers' casino because 
he got pains in his legs and knees in long drills. At the 
outset of the campaign, however, he withstood the heavy 
marching, although with difficulty. He was in his first actual 
skirmish September 20. A shell struck nearby and threw 
him several meters; whereupon he became unconscious and 
was carried away by the hospital corps. When he woke up 
he could not speak or hear. Ten days later, however, 
speech returned, and hearing returned in right ear; October, 
deaf in the left ear, and he could not hear a watch tick 
on the right side at a distance of 16 centimeters. He was 
examined at the otological clinic in Jena October 12, where 
the drum membranes were both found opaque, without 
reflexes or normal contours; hysterical attack on the caloric 
test. The next day, on the medical visit, there was a 
screaming attack. His plight seemed not so much simulation 
as one of traumatic hysteria. 

Again, after his stay at the nerve hospital, another hys- 
terical outburst was produced by a hearing test with vestib- 
ular apparatus, in the ear clinic, February 6, 191 5. The 
diagnosis was nervous deafness with involvement of left ear. 

The insomnia was successfully treated by sodium bicar- 
bonate. There was a slight improvement in speech. In 
March body weight had improved, but there was a marked 
tremor of the right hand. In the next few months there was 
a progressive improvement in general well-being, in speech 
disorder, and in tremor. The auditory disorder remained 
unchanged. The man now works in his father's garden. 

This case appears to show a combination of psychic and 
mechanical injury. There are severe hysterical auditory 
and speech disorders. Although the auditory disorder is 
of mechanical origin, the speech disorder appears to be of 
psychogenic nature. It is somewhat remarkable that the 
ear tests almost every time produce hysterical attacks in the 
form of convulsive crying. Rather unusual is the general 
cutaneous hyperalgesia, more marked about the ears. 



300 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock (distant, neither seen nor heard) ; left 
tympanum ruptured; semicoma eight days: Cere- 
bellar syndrome and hemianesthesia. Recovery, 
nine months. 



Case 218. (Pitres and Marchand, November, 1916.) 
A lieutenant underwent " shell-shock " either at night or in 
the early morning, September, 191 5, the shell bursting at a 
distance. He neither saw nor heard the shell, lost conscious- 
ness and was eight days semicomatose, failing to recognize 
his wife. 

On recovering his senses, he could not get about, as he 
had lost his memory, having to write down his room number 
and be warned of meal times. He was led about like a child. 
He had a continuous headache on the right side and pains in 
the occiput and along the spinal column, as well as in the 
right leg as far as the heel. These leg pains were lightning 
pains. Walking was difficult, staggering, leaning to left. 
Weakness of right arm and leg; right-sided hemianalgesia. 
Complete insomnia. During November there were frequent 
urgent desires to urinate day or night. Evacuated to the 
oto-rhino-laryngological center in Bordeaux, December 13, for 
examination of ears. The right ear was found normal, but 
there was a rupture of the left tympanum. There was at 
this time a trismus. The jaws were opened with the dilator 
and the man had a syncope during this operation. The 
question of surgical intervention for a cerebral lesion was 
raised, but he was first sent to the neurologists at Bordeaux. 
There, December 31, he was found with a facies of anguish, 
unstable gait, inclination to the left in walking ; no Romberg- 
ism; occasional dizzy spells. In walking, the right foot 
was pointed outward and on request to direct it forward he 
complained of pain in the loins, reaching as far as the scapula. 
Walking with eyes closed, he leaned to the left and lost bal- 
ance. With eyes open, no disorder of balance. With eyes 
closed, the body leaned backward. If requested to go back, 
he failed to flex his legs to keep balance. If he was asked to 



SHELL-SHOCK: NATURE AND CAUSES 301 

put a foot upon the chair in front of him, he immediately 
fell backwards. He could not support his body on the right 
leg more than a few moments. He had difficulty in raising 
both legs from the bed at one time and he could lift the right 
leg not so high as the left. Movements of the legs were 
performed hesitatingly and slowly and with greater diffi- 
culty with eyes closed. 

He could not thread a needle and could hardly dress him- 
self. Eyes closed, he could with difficulty perform the finger 
to nose test; eyes open, with much less difficulty. Adiado- 
chokinesis; muscular strength less in right than left; plantar 
reflexes absent; knee-jerks lively; hemianalgesia, right side. 
Loss of deep and bony sensibility on right side and diminution 
of testicular sensibility. Retraction of visual field, right; 
diminution of smell and loss of hearing, right; position sense 
absent on this side; stereognostic sense preserved. Men- 
tally, memory was poor; he was unable to read or do mental 
work. He slept little and had bad battle dreams. He was 
very impressionable and emotional and constantly com- 
plained of occipital pain. He had lost 8 kilos weight. 

He grew gradually better. In May he could go out alone. 
The muscular strength increased. The adiadochokinesis and 
synergic disturbances lessened ; the hemianesthesia persisted. 
In June there was greater improvement; in fact, there was 
no sign of disorder left except irregular sleep. 

We here deal with a cerebellar syndrome plus a hemian- 
esthesia. 



302 SHELL-SHOCK: NATURE AND CAUSES 



Mine explosion: Tremors, mutism, hemiplegia. 
Tremors cleared by hypnosis. Mutism replaced by 
stuttering. Persistent hemiplegia, probably organic. 



Case 219. (Smyly, April, 1917.) 

A soldier was blown up by a mine and rendered uncon- 
scious. Upon recovery of consciousness, the patient was 
dumb, unable to work, very nervous, paralyzed as to left 
arm and leg. The paralysis improved so that in the hospital 
at home the patient became able to get about. However, 
he threw his legs about in an unusual fashion. Several 
months later the patient was much improved. 

Shortly, there was a relapse. Transferred to a hospital 
for chronic cases, the patient was unable to walk without 
assistance on account of complete paralysis of the leg. There 
was insomnia, a general tremor, bad stuttering, and a habit 
of starting in terror at the slightest noise. 

Hypnotic treatment was followed by almost complete 
disappearance of the tremor. The patient began to sleep 
six or seven hours a night; nervousness diminished, and the 
stuttering slowly improved ; but neither the paralysis nor the 
anesthesia of the left leg was affected by suggestion. The 
leg remained cold, livid, anesthetic, and flaccidly paralyzed 
to the hip. A slight improvement has followed upon fara- 
dization but the patient still can walk only with assistance. 

Smyly regards this case as probably not a true case of Shell- 
shock, depending as he states " more on a lesion in the 
nervous system than in the psyche." 



SHELL-SHOCK: NATURE AND CAUSES 303 



Shrapnel bullet WOUND of skull: Unconsciousness 
(three weeks), followed by agraphia (three weeks), 
insomnia (six weeks), amnesia (six to eight weeks), 
hemiplegia (twelve weeks), impairment of vision 
(twelve to sixteen weeks), dreams (seven months). 
Recovery save for slight overfatiguability. 



Case 220. (Binswanger, October, 191 7.) 

A French tailor, aged 22, of healthy stock, was wounded in 
the left frontal bone in August, 1914. The shrapnel bullet, 
from an unknown distance, made a penetrative wound. The 
man was able to remember how at the moment he was injured 
he felt a sort of strain in his brain, felt his head with his hand, 
found he was bleeding, took out a bandage from his kit, re- 
moved it from its cover and without unfolding it put it on his 
head. At this moment he fell unconscious and there was then 
complete loss of memory for three weeks. This patient, 
who was intellectually keen, distinguished exactly between 
what he could himself remember and what he was told by his 
comrades. One of these had told him that he had cried out 
indistinctly that in a matter of fifteen days he would be well. 
He estimated the interval between his wound and the loss of 
consciousness as about five minutes. 

After three weeks, the tailor came to and remembers that 
the first word he heard was Munich. Astonished to be in 
Bavaria he asked for paper and pen to write to his people, 
but found he could not write, though still able to dictate a 
little to his comrades Besides agraphia there was hemiplegia 
on the right side, marked exhaustion, rapid fatiguability of 
vision, power of concentration but slightly diminished, and 
apathy for his surroundings; emotions normal. 

Three weeks later the power to write returned; after six 
weeks, sleep ; memory was restored in from six to eight weeks ; 
the paralysis disappeared in twelve weeks; vision became 
normal in three or four months; the dreams ceased after 
seven months. The mood for the first two months after re- 
gaining consciousness was slightly elevated; for another two 
months slightly depressed. The mood then became normal. 



304 SHELL-SHOCK: NATURE AND CAUSES 

There was, then, in this case complete recovery save for slight 
overfatiguability in a period of seven months. There were 
still a few residuals of hemiplegia. An operation in November, 
1 91 6, removed a shrapnel ball, one centimeter in diameter, 
from a dural scar. 

This is a case of acute reaction psychosis of exogenous origin 
lasting three weeks and leading to complete recovery in an 
after phase of from four to seven months. 



SHELL-SHOCK: NATURE AND CAUSES 305 



Normal subject, wounded and thrown to ground by 
shell explosion: Recurring MEMORIES of battle 
scene; persistently HYPERESTHETIC healed shell 
WOUND, with pupil and pulse changes on pressure 
of the scar. 



Case 221. (Bennati, October, 1916.) 

A lieutenant of artillery, student (one of his brothers dead 
of meningitis) , suffered somewhat from diarrhoea on the battle- 
field. He was, however, always able to obtain the best of 
food. External conditions did not seriously interfere with 
sleep. In particular there was no excessive dampness where 
he was. He was preoccupied with having to act as substitute 
for the commandant of the battery. He was not afflicted by 
the thought of his parents far away; their financial affairs 
were entirely satisfactory. 

This almost normal man was wounded after a day of in- 
cessant fighting five months after going to the front. When 
firing ceased, he withdrew with his soldiers to a trench. Here 
he was followed by an enemy gas shell which killed some and 
wounded others. While outside the trench shifting mutilated 
soldiers to the rear, he was hit by another shell of which a chip 
wounded him in the left thigh. He felt a terrible spanking 
blow that threw him to the ground and gave him great pain. 
He was carried on a stretcher to the medical post across the 
zone of fire; thence to a field hospital and from there to a 
hospital further from the front. He had been for almost 
seven hours in a sector of the fighting line which had been 
almost continuously active. 

The wound healed in less than a week. But what he had 
seen and felt kept tormenting his mind. There remained 
slight numbness in the wound where there was to be seen a 
spot of pigment, the size of a two-cent coin, with somewhat 
obscure outlines. The pain was irritated by damp weather, 
in certain positions, and by touch, and the pain on pressure 
was reflected in the pupils and in the pulse. 

No other disturbance, organic or functional, was found. 



306 SHELL-SHOCK: NATURE AND CAUSES 



Wounds; operation: Hysterical FACIAL SPASM. 



Case 222. (Batten, January, 1917.) 

A 23-year old soldier was admitted to the National Hos- 
pital for the Paralyzed and Epileptic, June 18, 1915, in the 
following state: He sat in bed, gasping, with the left side 
of the face set in a strong tonic spasm and jaws tightly set. 
The contraction of the masseters was such that his mouth 
could not be forcibly opened. He himself could separate 
his teeth for about a half a centimeter, but the jaws came 
together when a spatula was brought for insertion and then 
failed to relax. The facial spasm increased as the jaw was 
clenched more tightly. The patient said he was unable to 
breathe excepting when sitting upright, and when put into 
dorsal decubitus he breathed violently through his clenched 
teeth and held his breath as long as he could, " assuming a 
purple tinge," as Dr. Batten states, " which was apt to be 
disconcerting until one was accustomed to it." Faradism 
and force permitted the removal of false teeth but only to 
the accompaniment of shrieks, foaming, and violent move- 
ments of the arms, lacrimation, and sweating. During sleep, 
the face was at rest. The spasm of left face and of jaw would 
come on a few seconds after waking, when an observer was 
perceived. Attempts to force the mouth open invoked the 
same procedure as before in spite of the fact that the patient 
ate well. In a month he was virtually normal. 

It appears that May 13, about five weeks before, the 
patient had been struck by shrapnel on the right hand, fore- 
arm, and shoulder, and base of the nose, while in France. 
He had been dazed but had not lost consciousness, and the 
wounds had completely healed before arrival at hospital. 
It was about a week after being wounded that the patient 
was operated upon for removal of shrapnel from the face. 
Upon recovery from the anesthetic, the patient found him- 
self unable to move the right side of the face. Unable to 
remove his teeth, he had been fed by rubber tube. 



SHELL-SHOCK. NATURE AND CAUSES 307 



K 



Shell-shock : Hyperesthesia and over-reaction. 



Case 223. (Myers, March, 1916.) 

A stretcher-bearer, 19, who had had 18 months' service 
and 6 months' service in France, sent to Lieut-Col. Myers 
the day after admission to a base hospital, showed a remark- 
able condition of hyperesthesia and over-reaction. 

It appears that four days before, he had been blown up 
three times by aero torpedo mortar shells while attending 
the wounded. One had blown him into the air, another had 
blown him into a dug-out, and a third had knocked him down. 
Two or three hours later, having finished the job of carrying 
wounded to the dressing station, everything seemed to "go 
black" in the dug-out where he was resting, and from that 
time on he had been shaky. It seemed that he had hardly 
slept for several days before he finally gave in. 

There were irregular spasmodic movements of the head, 
arms (especially the right), and legs (especially the left). 
There were coarse tremors and incoordination in moving the 
arms. With eyes closed, he touched his nose with uncer- 
tainty. Cotton- wool touch on arms or head provoked lively 
movements. " I was always ticklish, " he explained, " but 
never like this; I can't stand it, Sir." Pinpricks produced 
almost convulsions. There was perspiration, rigidity of legs, 
and spasm such that knee-jerks were unobtainable. Plantar 
reaction, flexor. There were also visual hallucinations of 
bursting shells, and these were also heard when dozing. 

Improvement followed with rest, but about two weeks 
later, on waking to find himself being carried back to his 
tent to avoid a shower, he was so terrified that a special nurse 
became necessary. He was still jumpy the next day, alarmed 
at footsteps, and afflicted with headache. He improved 
further in three days; remained two months in hospital in 
England, had one month's leave, and then returned to light 
duty. 



308 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; thrown against wall; comrades killed ; 
no visible trauma, or loss of consciousness: Per- 
sistent TREMORS, augmented in intentional move- 
ments; CRISES of agitation following noise or 
emotion. 



Case 224. (Meige, February, 1916.) 

A corporal (an expert gunner) and his squad had just entered 
a mine shaft on Nouvron Plateau, January 13, 191 5, when a 
shell, bursting above them, threw him violently against the 
wall and killed or wounded several of his comrades. The 
corporal himself was not wounded, nor is it clear that con- 
sciousness was lost. The man lay waiting on the ground for 
some time until a communication trench could be finished 
and he could be evacuated without much danger from the 
mine shaft. He had already begun to tremble, and trembled 
still more while going back in the trench. 

He carried on there for a fortnight, always trembling, but 
not eating and no longer able to handle a gun. He was evacu- 
ated a month later and sent successively to Villers-Cotterets, 
to Meaux, to Courneuve (a month), again to Meaux, and 
finally to the neurological center at Villers-Cotterets, where 
he remained for two months (April 13 to June 15, 191 5). 
Here he was given the diagnosis of hysterical chorea by Guil- 
lain, and showed lively knee-jerks and Achilles jerks and great 
emotionality. The tremors were greatly increased when the 
cannon grew loud or bombs burst nearby. Lumbar punc- 
ture here showed a perfectly normal spinal fluid. He was 
then sent to the Salpetriere, June 19, 191 5, and was evacuated 
July 13 to a civil hospital until September 24, whence he was 
sent for convalescence to his home village, October 6 to 
December 15, from which he was returned to the Salpetriere. 

Throughout these transfers there had been no change what- 
ever in his status. For almost a year, as the result of a shell 
explosion, he had been trembling in precisely the same way. 
All four extremities trembled equally, unless the right arm 
and the left leg might be thought to tremble a bit more. The 



shell-shock: nature and causes 309 

tremor was equally pronounced in dorsal decubitus as in the^- 
sitting or upright postures, but ceased during sleep. The 

» tremors were worse in the evening and it was hard for the man 
to get to sleep. The eyelids and tongue showed a few irregu- 
lar, jerking movements, not synchronous with the tremor of 
the extremities. The head showed few tremors. The patient 
was able to diminish the trembling of the arms somewhat by 
keeping the elbows flexed at a right angle and held firmly to 
his body. If the tremor of the legs got more energetic, the 
patient would get up and take a few steps. Any movement, 
such as laying hold of an object, carrying a spoon or a glass to 
the mouth, led to an exaggeration of the tremors in such wise 
that the tremor of multiple sclerosis in its most extreme form 
was recalled. It was very hard for the man to eat. If the 
eyes were closed, the tremors grew more marked. The 
emotion caused by sudden noise or sharp command or memory 
of his trench life caused motor crises, with coarse, generalized 
movements, and even loss of balance. This agitation grew 
gradually less marked, but the tremors persisted. An at- 
tempt to test reflexes led to violent generalized contractions. 
There was no sensory disorder. The pulse was variable; at 
rest it stood at 60 ; if a table near by was struck suddenly, the 
pulse would go up to 120. 



310 SHELL-SHOCK: NATURE AND CAUSES 



Sharp gunfire: TREMORS; TREMOPHOBIA. 
A patient's (an artist) description of his feelings. 



Case 225. (Meige, February, 1916.) 

One of Meige's victims of shell-shock tremors was an 
artist. He stood the hardest sort of trench life for many 
months without disorder. Under particularly sharp fire, 
"the machine went off the track," as the artist said, and he 
began to tremble. Both arms and head trembled, but espe- 
cially the head, which was subject to small sidewise oscilla- 
tions, variable in degree, and almost permanent, — a sort of 
vibration which the patient could diminish somewhat by 
stiffening his neck muscles. His manual tremor was not 
exaggerated by voluntary movements. Superficially he re- 
sembled a Parkinsonian case. He presented a curious 
appearance of combined vibrations and stiffness. 

There was no doubt that this tremor had an emotional 
origin. In fact, the psychopathic status of the patient was 
described by the artist himself. "My nervous state, which 
I thought ought to last not more than a fortnight, still per- 
sists more than three, or almost four, months after being 
evacuated, although the trembling is a little less. I am 
calmer and palpitate less, and my hands perspire less when 
I am emotional or making an effort. At first, the slightest 
shock immediately ran through me, followed by an uncon- 
trollable trembling. Now there is an appreciable delay be- 
tween the shock and the trembling; I can control it for a 
few seconds but not longer. The subway gate noises, a 
flaring light, a locomotive whistle, the barking of a dog, or 
some boyish prank is enough to set off the trembling; going 
to the theater, listening to music, reading a poem, or being 
present at a religious ceremony, acts the same way. Re- 
cently when a flag was being raised at the Invalides, I thought 
at first that I was going to be cured by so moving a spectacle, 
but then I suddenly began to tremble so violently that I 
had to cry out, and I had to sit down, weeping like a child. 
Sometimes the trembling comes on suddenly without any 



shell-shock: nature and causes 311 

cause. I went to a novelty shop to do some errands with 
my wife. The crowd, the lights, the rustling of the silk, 
the colors of the goods — everything was a delight to me to 
look upon, — a contrast to our trench misery. I was happy 
and chatted merrily, like a schoolboy on a vacation. All of 
a sudden I felt that my strength was leaving me. I stopped 
talking; I felt a bad sensation in my back; I felt my cheeks 
hollowing in. I began to stare, and the trembling came on 
again, together with a great feeling of discomfort. If I can 
lean against something, sit down, or better, lie down, the 
trembling gets better and pretty soon stops. There are three 
conditions in which I feel well: first, upon waking after 11 
or 12 hours' sleep; next, after a meal, especially if it is a 
good one; and lastly, and above all, when I get the electric 
douche. Then, as if by magic, my ideas get clear, cheerful, 
and regain color ; I feel myself again. That lasts for an hour 
or so; then I relapse into my sad state." 

As to the tremophobia, this patient says "In the tramway 
or in the subway, I perceive that people are looking at me, 
and that gives me a terrible feeling. I feel that I am in- 
spiring pity. Some excellent woman offers me her seat. I 
am deeply touched; but if they look at me and say nothing, 
what are they thinking of me? This anxiety makes me 
suffer a good deal. If I am able to speak it is less painful 
to me, for then i is obvious that, despite my trembling, I 
am not a coward. What a sad situation this is!" 

Meige remarks that therapeutics is not especially suc- 
cessful in these cases of tremor. Sedative drugs, hyoscya- 
min, hyoscin, duboisin, and scopolamin, do not last long 
and should be used cautiously. Static lectricity works well 
in some cases. Rest isolation, and calm. 

As for the military prognosis, a period of observation of 
some three to four months may be necessary to learn the 
nature of the tremor. If the tremor then fails to alter, a 
convalescent leave for one or wo months may be given. 
The patient should then be re-observed by the same physician. 
Upon persistence of tremor, temporary invaliding. Tremors 
may be wittingly cultivated for medicolegal purposes (Bris- 
saud's sinistrosis.) 



312 SHELL-SHOCK: NATURE AND CAUSES 



Letters of a German soldier about his shell-shock. 



Case 226. (Gaupp, April, 1915.) 

A volunteer, 21, who had been in civil life a lackey, wrote 
as follows upon arrival in Gaupp's clinic: 

"On account of our privations and the various ter- 
rible scenes that you have to see, my nerves went 
back on me. Like the rest of the front, we too had to 
suffer terribly heavy artillery fire from December 20 on- 
wards. December 29 at eight o'clock in the evening, 
when I was about to mount guard at the camp, I was 
thrown down by a shell that unexpectedly struck near 
me across the earth pushed out into a trench. I ran 
at once to cover as some more shots followed directly. 
I couldn't be made to do anything on the thirtieth 
nor can I very clearly remember the events of that 
day. There was a terrific cannonade again, then cries 
of the wounded and the sight of the dead, etc. I was 
told afterwards that I fell down, cried, struck about 
me, and remained lying, dazed. The first that I can 
remember was that I was lying on a floor. I was then 
carried into another house, into a better room. Then 
I regained consciousness and could hear again after 
the noise in the ears had stopped, but I could not talk 
or walk. I was unconscious for two days. I got into 
the hospital train at R. the next day but had to be 
carried in as I could not walk. Travelling in the train 
made me quite foolish in my head and gave me bad 
headaches; I could not form any clear thoughts." 

It seems that this volunteer had not been quite up to the 
hardships of the war from the beginning; always a weakling, 
he had to be spared on the marches. In fact, he had been re- 
fused by the army at the first examination as unfit. He had 
been a nervous, tender, somewhat anxious fellow since child- 
hood. 

At the clinic there was an astasia and an abasia without any 
signs of organic disease. The striking feature was mutism. 
He could understand things spoken and written, but he was 
entirely mute, nodding and shaking his head properly for 
affirmatives and negatives. He carried with him a few slips 



shell-shock: nature and causes 313 

of paper with written requests, like: " Please, can I have salt; 
otherwise I can't eat the soup;" "Are we going to ride 
farther, I have such a bad headache. The doctor must not 
come. The one who wanted to shoot me if I couldn't speak. 
They are all bad." 

Treatment by suggestion (laryngeal faradization, lively 
verbal suggestion to pronounce single vowels, syllables, and 
whole words and sentences with enunciation of them) removed 
the mutism in a few days. At first the man's speech was low 
and somewhat retarded, but later it became entirely normal. 
Within ten days the abasia cleared up and the patient became 
lively and cheerful. He was depressed on finding that he had 
lice, but after losing them became happy and childlike again. 

February 1, however, on learning that he would be able to 
do garrison duty again, he took the news very soberly, and 
grew more quiet, trembled and seemed anxious. 

February 7, he was sent to the garrison, increasingly ex- 
cited. His own account of it in a letter written to a hospital 
nurse, runs as follows: 

"As you will see, I did not reach Dn. but only got 
as far as here [Another hospital]. I will tell you how 
it happened. Probably I ought to have remained in 
Tubingen for a while longer and perhaps then nothing 
would have happened to me. You will remember that 
I was more nervous and excited the last days than I 
had been before, and the cause was also known to you. 
I wanted to get home in some way and so I pretended 
to be as well as possible. That crying attack, or what- 
ever it was [an outcry in a frightful dream] had not 
been thought of by the physician any further, you know, 
and so I didn't think anything about it either. Then 
the head doctor asked me once if I had any trouble left. 
Well, I spoke out everything I had to say, but no further 
attention was paid to that either. Then when I took a 
walk and after walking slowly two hours could hardly 
stand, was trembling all over and had a high pulse and 
also a violent acute pain in the region of the heart, that 
wasn't of any importance either. Well, then I just got 
better from day to day and so I got what I wanted only 
too easily because they wanted the space and I certainly 
would have gone home and not to Dn. as I should have. 
[His reserve battalion was at Dn.] I got into the wrong 



314 SHELL-SHOCK: NATURE AND CAUSES 

train at St. so as to go home. I kept saying to myself, 
'You can't do that, it will be punished.' Nevertheless 
I couldn't act any other way because I was really sick 
from longing for home." 

Here he described an episode in a comrade who had lain 
beside him in the clinic, had gone off with him and had 
a hysterical excitement in Heidelberg so that he had to be 
detrained. 

"I was so awfully sorry to see him so miserable. I 
began to cry and was startled by every train coming from 
the opposite direction and by every loud noise. I was 
stared at by everybody in Frankfort and I could only 
cry more. Then a soldier scolded me because I was 
running senselessly up and down. Finally I got into 
the Leipzig train. Another guard questioned me. 
Everything then got more and more confused in me; I 
heard my mother call; then I heard shooting again; 
and finally I was entirely confused. I came to my 
senses in a room in the station toward evening, and was 
frightened again at a loud noise somewhere or a passing 
train. Then I was told what I had done in the train. 
I had cried out and raved, tried to get out of the car, 
called for my father and mother, wanted to go home, 
imitated shooting; allowed myself to be calmed a little, 
but began to shout again at every loud noise. When I 
was out of the train I bit a soldier and tore his whole coat 
open, so then I was carried to the hospital here in an 
auto. Up to this time I have been able to calm myself 
very well. The physician said that it was quite natural 
that I should not have very strong nerves yet. I must 
have beaten about and got knocked against things a 
good deal. There are bruises on my head and I am 
covered with black-and-blue spots." 



SHELL-SHOCK: NATURE AND CAUSES 315 

i 



A British soldier's account of his shell-shock. 



Case 227. (Batten, January, 191 6.) 

A British soldier, 22 years, who went out to France in 
November, 19 14, remained well until March 12, 191 5, when 
after shell explosion, he became unconscious for half an hour, 
and on recovery found he was deaf and dumb. He was able 
to think of words but could not say them. He remained 
dazed and frightened for a time, and still wakes up with a 
start at night. 

He was admitted to the National Hospital for the Paralyzed 
and Epileptic, March 25, 1915, and on March 27 recovered 
his speech suddenly and spontaneously. By March 29 
he had completely recovered and talked well. Dr. Batten 
remarks " how perfect the memory may be up to the time of 
concussion, and how complete the mechanism is for express- 
ing the ideas in written words when that for spoken words 
is abolished"; which may be seen from the patient's own 
account, as follows: 

I went out to France on the 3/11/14 and I was two 
days at Le Havre and then we went on to our 1st Batt. 
When we arrived at our destination the regiment was in 
the trenches so we had to go in. It was snowing hard 
and I felt it very cold. This was at Givenchy. We 
were relieved the following night and we went back 
for a rest. The next place we went to was just opposite 
Neuve Chapelle on the La Bassee Road and it was 
awful, the trenches were up to the knees in mud and 
water. The first night was very quiet, but the follow- 
ing morning about 9 p.m. the Germans started shelling 
and continued all day; the next was the same, but about 
1 o'clock the Germans were seen to be coming up in 
masses. They got to within a distance of about twenty- 
five yards, then they turned. They commenced shell- 
ing us again and they had another try about three 
o'clock but they did not get far. One of the men on my 
left had the half of his face blown away and we had 
about ninety- two killed and wounded. We got re- 
lieved after being in five days, then we went back for 
three days' rest. The next place we went to was Rue 



31 6 shell-shock: nature and causes 

de l'Epinette and we had an awful time there just be- 
fore Christmas. We went into the trenches and we 
were up to our middle in water and in some places it 
would have taken you over the head. We were in these 
trenches for twenty-four hours. There was nothing 
unusual happened and we got relieved by the Royal 
North Lanes. ; but we did not get far away; we had just 
got into our billets and were making some tea when 
the fall-in went and we were told that the Germans 
had broken through the North Lanes. We went away 
without any great-coats, and into the trenches we went 
for other seventy-two hours, and if the Germans had 
attacked again we could not have fired a shot as we 
were hardly able to stand for the cold and with the wet 
kilts on our legs it was awful. We got nothing to eat 
except three biscuits that some of the men went out 
and got. When we came out of the trenches on Christ- 
mas Eve we looked all like old men and a lot of them had 
to be carried. We went back for a rest to (Nervaille?) 
about thirty kilometers from the firing line for a month. 
When we came back again we went to La Bassee and had 
a pretty hot time there. The next place we were at was 
at that big fight at Neuve Chapelle when 472 guns 
bombarded the German trench for thirty-five minutes. 
At about 7 p.m. the word was passed along that we were 
to charge the German trench in front supported by 
the City of London Territorials. We got the trench 
all right and I got orders about 4 p.m. to go back to our 
own trench and bring along the belt-filling machine 
belonging to the machine gun. There was not a proper 
communication trench, there was a small dry ditch that 
ran out in the direction of the trench we had taken for 
a distance of 150 yards, the other 100 yards you had to 
come across the open. We got into our trench all 
right, and I got this box on my back and started back 
to the trench. I was just stepping out of the trench 
when a shell burst just over my head and I went down. 
When I came to my senses I was lying in our support 
trench where I had been carried by two of the men of 
the 4th Black Watch. One of them said something but 
I could not hear him and I tried to tell him so, then I 
discovered that I could not speak. 



SHELL-SHOCK: NATURE AND CAUSES 317 



Shell-shock by windage: Hysterical crural mono- 
plegia, of gradual development beginning four days 
after accident. Recovery by suggestion. 



Case 228. (Leri, February, 191 5.) 

A number of chasseurs were doing the " tortoise-shell " 
under bombardment, when the last chasseur in the line was 
blown forward above his comrades by a shell bursting about 
a meter behind him. He was projected some four or five 
meters, got up, walked four or five kilometers, found an auto- 
mobile, and was carried to Nancy. He passed, according to 
his story, red urine three or four times. He was six days at 
Nancy, where a slight abrasion of the side was treated. He 
began to feel heavy in his left leg on the fourth day. At 
Vendome, the paralysis got worse, and by November 17 
he had apparently a complete paralysis of the left lower 
extremity, called " spinal contusion." He walked upon two 
canes, dragging left leg behind and had to be carried upstairs 
on a stretcher. The reflexes were normal except that there 
might have been a very slight excess of the left knee-jerk. 
There was a slight hypesthesia of the left leg, sharply limited 
above. 

These phenomena were strikingly modified, at a single 
sitting, by verbal suggestion and faradism, but the man was 
one of those with mauvaise volonte. He did not want to get 
well so quickly, so that his complete cure was delayed a 
while. 



31 8 SHELL-SHOCK: NATURE AND CAUSES 



NATURE OF SHELL-SHOCK : At the nerve clinic 
the patient presents, e.g., sundry CONTRACTURES, 
of such a nature that they may be caused to DISAP- 
PEAR BY SUGGESTION, e.g., by mental influences 
during recovery from chloroform narcosis (note 
battle-dreams). PAINS and ANESTHESIAS dis- 
appear PARI PASSU with the contractures. The 
history is of shell explosion so near as to burn 
patient's clothing, fall with nosebleed, eight hours 
unconsciousness, crural monoplegia with anesthe- 
sia (crawled 3 meters, however). 



Case 229. (Binswanger, July, 191 5.) 

The treatment of a German private, 22, for contracture of 
the left leg and other phenomena, culminated in narcosis. 
Binswanger lays stress upon the mental influence to be 
exerted upon the patient at the conclusion of narcosis, at the 
moment in which the patient is particularly accessible to 
verbal suggestion. Treatment (see diagnostic details below) 
was carried out as follows: 

After a few days of essentially suggestive treatment with 
continued attempts at passive movements of the contracted 
joints (knee, ankle, toe), with steady concentration of the 
patient's attention upon the joints, a slight mobility in the 
toe joint on passive movement was obtained. 

After a few more days, the ankle became passively mobile 
to some degree; the patient exerted a certain resistance to 
passive flexion of toes and ankle. A week later, reflex con- 
tractions of the toes could be evoked by deep pin-prick. 
There had been an analgesia of both lower thighs and of the 
soles of the feet, and this analgesia remained unchanged. 
At this point, the subjective complaints of the patient, 
namely, noises in the head, especially in the left ear, and other 
cephalic sensations, tended to disappear and the patient 
felt subjectively better; yet there was still an intolerable 
itching of the head and spine. 



SHELL-SHOCK: NATURE AND CAUSES 319 

A month after the admission of the patient to the nerve 
hospital of the psychiatric clinic in Jena, there had been no 
essential change in the immobility and contracture in ex- 
tension in the left leg. Accordingly, with the permission 
of the patient, he was placed in deep chloroform narcosis, and 
the knee-joint was bent at a right angle and fixed in approxi- 
mately that position with a bandage. This experiment 
failed because, while the patient was waking out of his nar- 
cosis, the leg slipped back into extension, breaking the band- 
age. Accordingly, deeper narcosis was undertaken, and the 
leg fixed at a right angle in a plaster cast. 

While the patient was coming out of narcosis, it was 
evident that he had been dreaming of battle scenes. In 
fact, Binswanger remarks that these dream pictures and the 
words spoken while going under and coming out of narcosis, 
are curiously demonstrative of " sympathy with the enemy" 
for while waking out of narcosis, he cried: " Dost see, dost 
see the enemy there? Has he a father and mother? Has 
he a wife? I'll not kill him." At the same time, he cried 
hard and continually made trigger- movements with his right 
forefinger.* In point of fact, throughout his waking treat- 
ment, no one was able to learn what was going on in his mind, 
his sleep was good and deep, and his emotional state was 
entirely quiet and patient. 

As the patient was coming out of chloroform and regaining 
consciousness of his surroundings, he was repeatedly and 
persistently assured that the bending of his leg was now 
accomplished and the cramp removed. All that he would 
now have to do was to get back the strength of his leg. 

During the next few days he complained of violent pains 
in his left knee-joint and in the ankle-joint, but he remained 
in good spirits and full of confidence. Accordingly, in five 
days the plaster was removed and the contracture in the 
knee-joint was found to be completely absent; the knee was 
easily movable. The ankle-joint was but slightly movable. 
He could accomplish slight active flexion of the knee-joint 

* Compare sentiments of a Russian in narcosis (Case 319,. 
Arinstein.) See also Case 181 (Steiner). 



320 SHELL-SHOCK: NATURE AND CAUSES 

while lying in bed, and the toe-joint had already, before the 
narcosis, been both actively and passively mobile. After a 
few days, exercises in walking were begun. The patient had 
a little difficulty with his left knee-joint in walking, walking 
in fact as if with knock-knee. The foot was not well raised 
from the ground on account of the persistent stiffness of the 
ankle-joint. Walking, however, improved daily. He walked 
for three hours, resting at intervals. 

A sensory examination showed that the upper limit of the 
analgesia had come down five centimeters from its former 
level, now occupying the left foot and leg up to the junction 
of the lower with the middle third. There was now a zone 
of anesthesia interposed between the normal skin of the upper 
thigh and the anesthetic-and-analgesic skin of the lower 
thigh and leg. Upon the posterior aspect of the leg, the 
analgesia and anesthesia had disappeared to a point at about 
the middle of the upper thigh. 

About five weeks after the narcotic experiment, the ex- 
tended left leg could be actively raised while lying in bed, 
up to the full extent, with slight tremors. The patient 
described himself as fatigued by the active movements of this 
leg. The ankle-joint remained less effective. There was 
still a trace of resistance to passive movements. Although 
the passive movements of the toes were normal, active move- 
ments of these were weak and hard to execute. There was 
still a trace of difficulty at the knee in walking and the gait 
was awkward, trepidant, precipitate. He could get about 
without a cane, however. If unobserved, his posture was 
more certain and free. If he exerted himself hard, severe 
parietal headache on the right side would develop. 

It was then proposed to the patient that another narcosis 
would rid him of the stiffness in his ankle-joint. He feared 
narcosis and was told that regular and energetic voluntary 
movements would also rid him of the stiffness. These will 
exercises consisted in his directing his whole attention to his 
left ankle-joint until he felt it. Then he was given the 
command: " Let go the joint" — whereupon he would take 
his attention away from the ankle-joint at once. In this 
way, he was told, his will would make the ankle-joint mobile. 



SHELL-SHOCK: NATURE AND CAUSES 32 1 

Meantime he was given twice daily a gram of bromophen- 
acetine for his parietal headache. 

The result was a rapid recovery. There were still a few 
traces of difficulty at date of report. The zone of sensory 
loss had retreated to the ankle, with a cuff-like zone of hypal- 
gesia above the definite zone of analgesia and anesthesia. 

As to the previous nature of this case, although there was 
neuropathic heredity on the mother's side, there had been no 
sign of any individual neuropathic disposition. He had been 
a volunteer since 191 1 in a guard regiment of infantry. His 
military training had been well borne; in the war he had 
fought through 20 battles. On November 11, 1914, in a 
storming attack, he had had his breeches burned from the 
effects of a shell. He had fallen, unconscious; the uncon- 
sciousness lasted about eight hours. He found on awaking 
that he had had nosebleed. When he wanted to get up, he 
found that his left leg was completely paralyzed and insen- 
sible ; in fact, he thought it had been cut away. He crawled 
for about three meters to a trench in which there were several 
wounded. In the evening he was taken by automobile to a 
field hospital, and on the 17th was removed to a reserve 
hospital at Erfurt. Thence he was transferred to the Jena 
Hospital, January 25, 1915. 

A strongly built man, with many reflexes increased and a 
lively dermatographia. The reflexes of the left, or contrac- 
tured, leg were lacking; the mastoid processes were painful, 
and the occiput and temples were painful to percussion. The 
spinous processes of the vertebral column in the lumbar re- 
gion were painful. The other phenomena have been suffi- 
ciently indicated above. The head sensations were peculiar; 
there were no pains but a peculiar itching. Contraction of 
the fingers of the left hand was painful. There was a feeling 
as if there were lice under the skin in the left upper thigh. 
There was itching in the nose, which the patient described 
as due to the sulphur " out there," meaning shell gases. 
Sleep and appetite were good. Memory was imperfect: he 
could no longer remember the names of the battles, and of 
late had had to count on his fingers to find out how much 
was 2 times 2. As to the curious parietal headache, con- 



322 SHELL-SHOCK: NATURE AND CAUSES 

tralateral to the contractured leg, Binswanger inquires 
whether we may not here have to do with localized vascular 
phenomena of the brain part which might conceivably be 
related with the innervation of the leg. Binswanger remarks 
that if the plaster cast be left on too long, it may happen that 
hysterical contracture will take place in the new position. 

As to the will exercises used in the present case, Bins- 
wanger remarks that the patients must be intelligent and 
attentive, and naturally they must desire to get well. Fortu- 
nately, many of the war hysterics do want to get well, since 
the contrary experience is had invarious industrial cases. 



shell-shock: nature and causes 323 

L 



Wound of thigh: Pseudocoxalgic monoplegia with 
anesthesia. Cure of anesthesia by faradism at one 
sitting. Cure of lameness by reeducation and 
electricity in one month. 



Case 230. (Roussy and Lhermitte, 1917.) 

An infantryman, observed at Villejuif, February 9, 191 5, 
was suffering from a right-sided crural monoplegia of a pseu- 
docoxalgic type, following a wound September 9, 19 14. The 
wound had been a through-and-through one in the upper 
right thigh. Every active movement could be performed 
as well on the right side as on the left; but the strength of 
the movements was less on the right, especially that of leg- 
extension. The reflexes were normal, the lameness was 
slight, with toeing out; the sole came down flat upon the 
ground. There was an absolutely complete anesthesia of 
the entire right leg and side up to the umbilicus. 

Energetic faradization of the skin caused the anesthesia 
to disappear the day the patient was brought to the hospital. 
The cure of the lameness required a month of reeducation 
and electricity. 

According to Roussy and Lhermitte, crural monoplegia is 
less frequent than brachial monoplegia. The flaccid form is 
rare, and when it occurs, complete, though the patient al- 
ways remains capable of executing some voluntary move- 
ments and can walk with crutches or cane. During the 
automatic movements of walking, some muscles may be 
observed to contract that remain immobile when the patient 
is being examined recumbent. Naturally such a difference 
in contractions standing and lying, would be very exceptional 
in a case of organic monoplegia. 



324 SHELL-SHOCK: NATURE AND CAUSES 



Contusion of thigh: HYSTERICAL right crural 
MONOPLEGIA. An ORGANIC CRUTCH PAR- 
ALYSIS develops in the right arm, unobserved by 
the patient whose main concern is his useless leg. 
Cure of leg by psychotherapy. 



Case 231. (Babinski, 1917.) 

A certain lieutenant, following contusion of the right 
thigh, developed a crural monoplegia of hysterical nature. 
In fact, although the paralysis had lasted several months, the 
tendon reflexes, the skin reflexes, and the electrical responses 
of the muscles, were absolutely normal. Moreover, the good 
effects of psychotherapy confirmed the hypothesis. But 
besides the hysterical crural monoplegia, there was a radial 
paralysis on the right side, clearly organic in nature, due to 
the nerve compression by the crutch which the patient had 
employed on account of the paralysis of his leg. 

Babinski notes that this association of conditions was 
remarkable in that it demonstrated that hysteria and simu- 
lation should not be confounded with one another. To be 
sure, it is difficult to tell simulation from suggested phe- 
nomena, for there are no objective characters that demarcate 
the two. Babinski had himself said that hysteria was a 
demi-simulation ; but a demi-simulation is not a simulation. 
The patient was in fact, sincere enough in his belief that he 
could not move his leg. To obviate this paralysis, he had 
in fact leaned so conscientiously upon his crutch that an or- 
ganic paralysis, had resulted. In fact the radial palsy had 
only been discovered incidentally, and the paradox appeared 
that a purely imaginary trouble occupied in the patient's 
mind for a long time a much more important place than the 
genuine organic trouble which accompanied it. 



shell-shock: nature and causes 325 

c 



Bombardment; war strain; gassing?; collapse; 
arthritis: Hysterical MONOPLEGIA and ANES- 
THESIA of leg, interpreted as a " PROTECTIVE " 
reaction. Later, monoplegia and anesthesia of arm. 



Case 232. (MacCurdy, July, 1917.) 

A corporal described as normal (" except for some shyness 
with the opposite sex ") adapted himself well to training and 
went to France in May, 191 5, where he was at once thrown 
into 18 days of almost continuous bombardment. After 
some initial fright, he settled down to work well enough, but, 
when the weather got bad in September, 191 5, grew tired of 
the situation. Bad dreams began (falling into a deep hole; 
being shelled). He thought of suicide, wanted a shell to 
incapacitate or kill him, began to have pains in the head, 
arms and legs, and was already groggy when a gas attack 
came. Whether he got a whiff of the gas or not, he at any 
rate felt giddy, got a swallow of water, and when the gas 
passed got out of his dugout in the open air. He was fatigued 
and much relieved when the company was ordered back. 
Now, however, he got shaky and fell in a collapse on a pile 
of straw, without, however, losing consciousness. 

Apparently he had an attack of acute articular rheuma- 
tism. There was a sore throat and a pain in the head, 
radiating to left shoulder and to finger tips, with pain also 
in legs. The pain was worse in the right leg on moving the 
knee-joint. These pains lasted for a month in hospital. 
The leg had been like a log since the collapse on the pile of 
straw. Even after the pains left him a month later, the 
right leg was paralyzed and anesthetic. He walked with a 
crutch and developed a crutch palsy. After a month a 
hysterical paralysis of the right arm, with superficial anes- 
thesia, supervened. During a period of eight months there- 
after improvement was steady under reeducative measures. 

According to MacCurdy's analysis, the acute arthritis led to 
paralysis as a protective reaction. The paralyses are disa- 
bilities that would ensure absence from the front. 



326 SHELL-SHOCK: NATURE AND CAUSES 



Lance-thrust in back, rapidly healed. Paralysis of 
right leg, disappearing with rest and exercises. 
Later, psychotic symptoms, with recovery. 



Case 233. (Binswanger, July, 1915.) 

N. H., 21, a laborer, industrious and sober (mother healthy, 
father insane and a suicide; patient somewhat sickly in 
childhood after pneumonia, a good scholar) volunteered at 
the outbreak of the war. Early in November he was on the 
Eastern front. November 17 to 22 he was in a number of 
small reconnoitring skirmishes almost daily, as a cavalry- 
man. On the 22d, there was a clash with a Cossack patrol 
of far superior numbers. Eight German horsemen cut their 
way through, riding about 4 kilometers back to their squad- 
ron. 

While dismounting, N. H. discovered that his back was 
wet. It occurred to him at once that he had been wounded. 
However, he successfully dismounted and then collapsed, 
feeling as if his right leg had fallen asleep. His companions 
found a wound in his back, which had come from a lance- 
thrust. The wound was bandaged. He was transported to 
Germany on a peasant's wagon, the trip occupying six days, 
and on December 6 he came to the surgical clinic in Jena. 
The wound was insignificant and healed quickly. 

The leg remained motionless, and on December 10 the 
patient was referred to the nerve hospital. He was a small, 
slenderly-built man, with poor nutrition, weighing 108 
pounds. The scar, about 1 cm. long, alongside the thoracic 
vertebra, was still somewhat red and but slightly sensitive 
to pressure. Neurologically, the knee-jerks and Achilles 
jerks were greater on the right than on the left, and there 
was on the right side a distinct patella and ankle clonus. 
There was no Babinski reaction on either side. 

The movements of the right leg were not of wide excursion, 
and flexion and extension of the knee and ankle-joints, while 
lying on the back, were slowly and hesitatingly performed, 
with an expression of pain, and with visible effort by the 



SHELL-SHOCK: NATURE AND CAUSES 327 

quadriceps muscles. Flexion and extension of the toes were 
likewise difficult, and when the toes were stretched there was 
a distinct contraction of the tibialis anticus. Electrically 
the muscles were normal. On passive motion, there was 
slight spastic tension in the musculature of the right leg, and 
the patient said he felt marked pain. In walking, the right 
leg was moved with a limp and with the evident design of 
sparing it. The knee was imperfectly bent and the sole of 
the foot was dragged along the ground. There were short 
out-throwing movements of the lower leg. 

Pain sense was normal, or possibly slightly in excess. 
There were painful points on pressure on the lower part of 
the os sacrum and coccyx and over the right sciatic and tibial 
nerves. Intelligence examination showed school knowledge 
to be extremely poor and calculation ability poor. Critical 
judgment and reasoning power were deficient. Memory 
and perception were without marked disturbance. The 
patient was dull and without interest in his surroundings. 
He complained that his right leg was as if dead and that he 
felt great pain in any attempt to move it. He also complained 
of pains at night in the region of the right shoulder and neck. 
His nerves, he said, had been very weak since his trip back 
from the front, during which trip he had been very cold and 
poorly cared for. 

Treatment consisted of rest in bed, application of moist 
packs to the right leg, active and passive exercises of the 
right leg. After ten days he made his first independent 
attempts to walk, and active movements of the right leg in 
dorsal decubitus became unrestricted and painless. He re- 
mained somewhat unsteady in station, showing bilateral 
twitchings and movements of the right leg muscles. In 
walking the right leg was dragged behind in a spastic-paretic 
fashion. Appetite improved ; spasms decreased ; but at the 
end of December foot clonus was still persistent. 

Upon January 10 there was an odd mental change. He 
became seclusive and suspicious. January 15 he expressed 
ideas of poisoning; his sister, he said, wanted to poison 
him, and others were watching him suspiciously; his room- 
mates were talking about him; in fact, he thought one 



328 SHELL-SHOCK: NATURE AND CAUSES 

comrade was an Englishman. Sleep was poor. At the end 
of January, after a short period of improvement, he again 
had ideas of being poisoned, and had dream-like, unclear 
thoughts. His actions became incoherent: he would un- 
dress suddenly in the daytime and go to bed, getting up five 
minutes later and dressing. Senseless postcards were written. 

This condition lasted a few days only, whereupon the 
mental and bodily condition greatly improved. Daily walks 
were then taken in the garden and in the city without ex- 
ertion. The ankle-clonus on the right side was now decidedly 
weaker but did not entirely disappear. The muscle power on 
the right side was somewhat less than on the left. 

The patient was very homesick, and on March 14 was 
sent home. 



SHELL-SHOCK: NATURE AND CAUSES 329 



Shell-shock — six days later, crural monoplegia, 
cured by suggestion. " Metatraumatic " hysteria. 
HYPERSENSITIVE PHASE AFTER SHELL- 
SHOCK. 



Case 234. (Schuster, January, 1916.) 

On August 13, 191 5, a soldier was knocked unconscious 
by the explosion of a shell nearby. He woke up several 
hours later with headache, noises in the ears, itching, but no 
trace of paralysis. 

Six days later, on August 19, he was released from hospital, 
still free from paralysis. On the railway journey he met 
some people of his district by whom he sent greetings to his 
wife, meanwhile becoming greatly excited. When he tried 
to get out of the train he noted a weakness of the left arm and 
left leg; this weakness somewhat quickly grew into a severe 
paralysis, so that when observed in Berlin the left leg was 
entirely paralyzed, not a single muscle of which could be 
moved when the patient was examined by Schuster one 
month after the accident. There was also a hypesthesia on 
the left side with total anesthesia of the left leg, which 
anesthesia was related stocking-wise to the hypesthesia of 
the trunk. There was tremor of the hands as well as general- 
ized increase of reflexes. The plantar reflex, though weak, 
was flexor. The pulse rapidly ran up under excitement. In 
short, the patient seemed to be suffering from hysterical 
palsy. Waking suggestion did so well with the man that 
after three weeks normal sensibility was restored to the leg, 
and he could walk tolerably well without a cane. 

The point of interest in this case is that the symptom of 
greatest importance, namely paralysis of the left leg, did not 
arise until six days after the shell explosion and then only 
after the man became excited by thoughts of his home and 
family through meeting his town people. The term meta- 
traumatic is suggested by Schuster for cases of this sort. The 
emotions and stresses of war may be regarded as labilizing 
and sensibilizing the nervous system sometimes for months. 



330 SHELL-SHOCK: NATURE AND CAUSES 



Wound of left foot: ACRO CONTRACTURE. 
Psychoelectric cure, about seven months later, at 
one sitting, except for some residuals that cleared 
shortly afterwards. 



Case 235. (Roussy and Lhermitte, 191 7.) 

A soldier, 21 years, was observed at the Centre Neuro- 
psychiatrique, August 30, 191 6. He had been wounded in 
battle, March 16, 191 6, near the left internal malleolus. 
Infection followed and inguinal adenitis, for which he was in 
hospital a month. 

Even before the abscess began, the foot had begun to twist 
inward. After the abscess had been cured, a contracture 
set in permanently, and at entrance to hospital was irredu- 
cible. The knee-jerk and Achilles jerk were more active on 
the side of the equinovarus contracture. There was even a 
slight amyotrophy of the calf. There was no appreciable 
vasomotor disorder. The foot and lower part of the leg were 
a little warmer on the left side. 

Cure followed a single sitting with psychoelectric treat- 
ment, at least so far as the contracture went. Pain and 
swelling remained in the evening, followed by fatigue. The 
patient was discharged cured, October 12, 191 6. 

Hysterical pes equinovarus shows the foot immobile as if 
frozen (fige). The foot is extended with the toes lowered 
and the internal border incurved, as if revolved about the 
axis of the leg. The surface of the sole is directed inwards 
and much furrowed. The tendon of the tibialis anticus is 
very prominent. The internal malleolus is hardly visible, 
while the head of the astragalus is easily made out. No 
passive movement is possible and the tibiotarsal and medio- 
tarsal joints are quite out of function. Upon palpation, the 
excessive contracture of the anterior muscles of the leg is 
striking. Upon request to move the foot, the foot is not 
moved, but muscles of the lower leg may contract, and even 
those of the thigh. 



SHELL-SHOCK: NATURE AND CAUSES 33 1 

There were no sensory disorders in the present case, though 
they often do occur in this form of acrocontracture. It is 
doubtful whether the skin changes sometimes seen, such as 
hypothermia, hyperidrosis, cyanosis, and glossiness are due 
to circulatory disorder induced by the contracture or to the 
prolonged immobility. It has been proved by Meige, Benisty 
and LeVy, that even in a normal subject prolonged immo- 
bility may cause a difference of temperature of several degrees. 
Circulatory disorders sometimes cease immediately upon 
cessation of the contracture. Roussy and Lhermitte insist 
upon energetic and early treatment of these psychoneuro- 
pathic acrocontractures, which are apt to proceed less 
favorably than the acroparalyses. If not treated energeti- 
cally and early, actual nerve, tendon, and bone lesions may 
ensue. 






332 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; shell-wound; emotion: Hysterical 
paraplegia. Approximate recovery. 



Case 236. (Abrahams, July, 1915.) 

A private of the First East Lanes could remember a 
shell's bursting and striking a wagon near him when he was 
carrying food to the firing-line. He also thought a spare 
wagon wheel might have fallen on him. A period of uncon- 
sciousness of four or five days duration elapsed, on recovery 
from which he found himself suffering from a shell -wound in 
the left buttock, complete paralysis of both legs, and pain in 
the back, by the fourth lumbar vertebra. He thought that 
he had suffered from sphincteric paralysis for eleven days af- 
ter the accident; but by September 25, there was no sign of 
this. Besides the paraplegia, there was complete loss of sen- 
sation below Poupart's ligament in the right leg, reaching as 
high as the iliac crest behind; and an anesthesia of the left 
foot including heel and sole, with anesthesia to light touch 
throughout the limb (pin-pricks being appreciated in a nor- 
mal way as far as the ankle) ; and there was an anesthesia to 
touch and pain in the ulnar distribution. 

April 20, 1 91 5, the patient was found to be a robust, 
somewhat micrencephalic, slowly cerebrating subject. Total 
flaccid paralysis of legs; right knee-jerk slightly exaggerated; 
no plantar response of any sort was obtainable. Right leg 
entirely anesthetic; left leg and both arms showed a dimin- 
ution of sensibility; suggestion of glove and stocking anes- 
thesia; trophic changes absent. The scar of the healed 
bullet-wound lay over the trunk of the left sciatic nerve. 

It seems that the man's companion had both his legs 
blown off at the time the shell burst. It is questionable 
whether the paraplegic patient actually saw the legs blown 
off, or merely heard about the accident. Another psychic 
feature lay in the fact that the patient had a paralyzed 
sister — a possible financial burden. 

April 30, nitrous acid anesthesia. During the temporary 
rigidity, the legs were found to stiffen slightly; the legs were 



SHELL-SHOCK: NATURE AND CAUSES 333 

flexed. Upon the return of consciousness, the patient was 
told that the legs had moved during anesthesia, and was 
asked to place them in a more convenient position. The 
thighs moved slightly, and throughout the day movements 
were encouraged against resistance. 

The next day he was gradually raised to the vertical 
position and supported upright. But at this stage he had 
become mentally resistant and resentful. During the day 
the upright position was at intervals resumed, and the patient 
was made to walk between two attendants. The next day 
he walked alone and his mental resistance had broken down. 
There was no longer any evidence of exhaustion and effort 
in the movements, and the patient began to take pleasure in 
his recovery. 

Improvement was progressive. A pronounced hysterical 
element persisted, encouraged by the perpetual attentions of 
visitors. When discharged, there was a slight hemi-anes- 
thesia throughout the right side, and a doubtful patch of 
anesthesia on the dorsum of the foot, sole, and plantar sur- 
face of the heel. 



334 shell-shock: nature and causes 



Shell-shock; burial; flexion of spine: Paraplegia. 



Case 237. (Elliot, December, 1914.) 

A reservist, 34, formerly army instructor in gymnastics, a 
member of the 1st Battalion King's Royal Rifles, was sub- 
ject to injury from the bursting of a " Black Maria " on his 
trench. He was sitting with bent back in his shelter, with 
legs fully extended. He was in a small dug-out, a recess 
excavated under the earth backward from a narrow trench 
and not timbered. The "Black Maria" burst and covered 
him up to the chin in a heavy clay soil. After building up 
the breach twenty minutes later, his comrades dug him out. 

He had received on his body the violent impact of the mass 
of earth pushed laterally from the crater excavated by the 
bursting of the shell. Accordingly his vertebral column was 
forcibly flexed, its ligaments were stretched, and hemorrhages 
were produced in the great muscles of the back. As the 
twelfth thoracic vertebra is the weakest spot in the spine, 
the roots of the cauda equina opposite this weak spot were 
probably injured. Such accidents are met in mines. 

The legs were powerless and numb. There was nausea, 
no vomiting, no gas, no dizziness or trouble in the head, 
not even pain in the small of the back. The accident had 
occurred at 8 a.m. Upon nightfall, he was removed on a 
stretcher to the field hospital, arriving at the base hospital 
four days later; and on the fifth day power began to return 
to the legs. Knees, ankles, and toes would move slightly 
November 6, though passive movements of the legs caused 
pain in the back. The deep reflexes were weak, the plantar 
reflexes flexor. The left cremasteric reflex was weaker than 
the right. Impairment of sensation was slight in both ex- 
tremities, but the left leg was a little more numb than the 
right. The left lower abdominal reflex was lost. A band of 
hyperalgesia corresponded with the left eleventh and twelfth 
thoracic segments November 12, slight reflex disorders and 
some degree of paresis of the legs. 



SHELL-SHOCK: NATURE AND CAUSES 335 



Shell explosion: Paraplegia; sensory symptoms. 



Case 238. (Hurst, January, 1915O 

A lieutenant, 23, came to the ambulance September 15, 
1 9 14, having the morning before been to the firing-line with 
his company and thrown to the ground on his back by the 
explosion of a shell which he had seen falling behind him. 
He had not lost consciousness, but was unable to rise. After 
a night in the relief post, he was brought by automobile 12 
kilometers to the ambulance. He complained of pain in the 
back, though no wound or ecchymosis could be found there, 
nor any painfulness of spinous processes or irregularity of 
bone. He had not emptied the bladder from the time of 
the shock. Preparations were made to catheterize on the 
morning of the 16th, when the patient after effort became 
able to micturate. There was crural paraplegia such that 
he could not sit or walk even when supported. Lying down, 
he could move his legs slightly sidewise. Anesthesia to pin- 
prick and temperature was complete to the groin ; but tactile 
anesthesia was found only in the sacral root territory, namely 
in the feet, the outer aspect of the legs, the posterior surface 
of the thighs, and the scrotum. There was loss of sense of 
position for the toes. The plantar reflexes were abolished; 
but there were no other reflex disorders; nor was there any 
evidence of other disorder. 

September 20, the man was evacuated by sanitary train 
in the same status as at entry. January 27, 191 5, the patient 
could walk on crutches, supporting himself in part on the 
left leg. The lumbar pain had largely disappeared. 

Hurst regarded this case as one of organic origin due to 
commotio spinalis. 



336 SHELL-SHOCK: NATURE AND CAUSES 



Wet, cold, heavy marching; leg pains, rheumatic; 
no other somatic factor or any emotional factor dis- 
coverable : Transient paraplegia ; two months after 
period of exposure, brachial tremor, hysterical. 
Recovery incomplete. 



Case 239. (Binswanger, July, 1915.) 

A German soldier, 34 (non-alcoholic; married, father of 
five healthy children; on military service 190 1-3; regarded 
as a very good soldier; father alcoholic), got bad leg pains 
from wet and cold in West front trenches September 8-13, 
1 914. Still he was able to march some 30 kilometers. But 
two days later (he had lain down in wet clothes in a barn), 
his legs became quite immobile. He was in a reserve hos- 
pital from November 3. The rheumatism disappeared, and 
suddenly, early in the morning of November 8, when he was 
washing, a lively tremor and shaking of the right arm set in. 

Examination at Jena January 30, 1915, showed no special 
physical disorder. The sense of touch was slightly dimin- 
ished on the right side; the pain sense was normal; move- 
ments were free. While at rest there was a continuous 
shaking tremor of the right arm and hand, which consisted 
of very rapid pronations and supinations, and shaking move- 
ments of the upper arm. At times the tremor would com- 
pletely cease, and when attention was diverted the tremor 
became slighter or quite disappeared. The tremor increased 
when it was talked about in the man's presence. The left 
grip was stronger than the right. 

January 31, after he had been in bed one day and treated 
with moist packs, the shaking suddenly ceased. He then 
complained only of mild pains in the right shoulder and 
wanted to get up. 

February 23, he was given three days' home leave, which 
he stood very well. He now began to take part in the 
medical gymnastic work, but complained afterwards of more 
pains in right shoulder and arm. There was a lapse into the 









SHELL-SHOCK: NATURE AND CAUSES 337 

shaking tremor, which lasted with varying intensity for 
several weeks. Loud noises or calling made it worse. 

Hypnotism and suggestive treatment of the tremor were 
without effect March 25. March 26, on passive extension 
of the right arm, patient complained of pain in shoulder and 
arm. Next day the tremors were more marked, but March 
29, the tremors suddenly stopped altogether. April 4, the 
pains stopped never to return. April 15, he was given leave 
to go home for spring farm work. 

Four weeks later he returned, sparing his right arm, which 
he held stiffly beside his body when walking. If he let the 
arm hang free in walking, rhythmical movements in it began. 
He complained of painful involuntary contractions in the 
right arm even when in complete rest. Nor did the con- 
dition afterward essentially change; the patient went home 
at the beginning of July. 

The remarkable feature of this case is the complete lack of 
any emotional shock. The total genesis seems to have con- 
sisted in the prolonged exposure to wet and cold, and the 
heavy marching. The tremors, limited to the right upper 
extremity, occurred without any demonstrable psychic or 
bodily trouble, and set in after the disappearance of the so- 
called rheumatic disorder. Although there is no one psycho- 
genic factor to single out, the psychic influencibility of the case 
is unmistakable; moreover, the incompleteness of the cure is 
doubtless, according to Binswanger, a matter of the imper- 
fect suggestive therapy employed. 



338 shell-shock: nature and causes 



Fever patient watches barrage coining: uncon- 
sciousness, paraplegia: recovery. 



Case 240. (Mann, June, 1915.) 

A lieutenant was lying with fever in a farmhouse in upper 
Alsace, watching from his window the shelling of a battery 
about 400 meters away. He saw that the enemy was to 
reach the farm with shell in due course of time. The shells 
came nearer, say up to about 100 meters, and the lieutenant 
was able to reckon closely when he would be reached. He 
was quite defenseless and unable to get to safety. At the 
very moment, he thinks, when the shells began to strike the 
house, the lieutenant lost consciousness from fear. He was 
unconscious an hour before being carried to the cellar. The 
shelling lasted several hours more. Immediately upon com- 
ing to the patient found that, although he bore no external 
wound, both legs and the right arm were paralyzed. 

There were never any signs of organic disorder. The pa- 
tient recovered completely with purely suggestive treatment. 



Incentives to paraplegia. 



Case 241. (Russel, August, 191 7.) 

A young Canadian paid $150 to have his teeth repaired 
to be accepted for service and then married. The wife 
became pregnant. He reported sick after falling out on a 
route march in a heavy rainstorm. The medical officer said 
he had weak feet and ankles. He lay around the huts, was 
excused duty, and got worse in the wet and cold. He was 
admitted to hospital and came to Russel' s wards on a 
stretcher showing paralysis of both legs with slight power of 
movement at the knee. Stroking anesthesia to pin prick 
from the knee down. Reflexes not abnormal. He walked 
back upstairs! 

According to Russel the wife's pregnancy had furnished a 
sufficient incentive, and the M. O.'s suggestion had fallen on 
fertile soil. 



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SHELL-SHOCK: NATURE AND CAUSES 339 



Bullet wound of back: Hysterical bent-back 
camptocormia. 



Case 242. (Souques, February, 191 5.) 

A man was wounded September 6, 1914, by a bullet that 
entered along the axillary border of the scapula and emerged 
near the spine. He spat blood for several days ; but the skin 
wounds quickly healed. 

When he got up, his trunk and thighs were found to be in a 
state of moderate flexion upon the pelvis, the trunk being bent 
almost at a right angle; the legs were flexed somewhat upon 
the thighs. The man could not voluntarily extend his trunk, 
but he could extend his thighs to a moderate degree. He 
could bend his trunk still further forward than its habitual 
contractured position, being able to pick up an object from 
the ground. If the man was put in the ventral position, the 
trunk could be straightened to a considerable degree. Curi- 
ously enough, the man felt no pain, nor had there been any 
pain since the healing of the wound. No motor, sensory, 
reflex, trophic, vasomotor, electrical, visceral, or X-ray dis- 
orders could be found. It was evident that there was a 
contraction of the muscles of the abdominal wall and of the 
iliopsoas, yet it was also clear that these muscles were not 
contractured on account of the subject's ability to flex his 
trunk and to extend his thighs. 

Here, then, is a vicious attitude crystallized (in the phrase 
of Souques) in the form of a pseudocontracture. 



340 SHELL-SHOCK: NATURE AND CAUSES 



Blown up by shell; unconsciousness: Campto- 
cormia (bent-back, " cintrage "). Cure by corsets. 



Case 243. (Roussy and Lhermitte, 191 7.) 

Camptocormia with antero lateral bending is described 
by Roussy and Lhermitte in an infantryman observed at 
Villejuif, February, 191 5, after having been wounded Septem- 
ber 3, 1 9 14. The infantryman had been thrown into the 
air by the bursting of a shell, had lost consciousness, and 
came to with violent pains in the back. The trunk was 
found to be bent strongly forward and to the right side, and 
remained in this position thereafter. There was no evidence 
of wound. 

In February, 1916, a plaster corset was applied by Souques, 
which brought the patient partly to normal station in three 
weeks. The trunk was now no longer bent forward, but was 
still bent to the right. A second corset was applied for 
three more weeks, with which the patient became absolutely 
straightened out again. He was discharged cured and sent 
to the Grand- Palais for the reeducation course. 

This condition is a form of trunk contracture in the nature 
of a kyphosis (scoliotic and lordotic forms of contracture are 
also found in the hysterical group), for which the terms plica- 
ture of trunk, traumatic kyphosis, pseudo-spondylitis, and 
camptocormia have been in use. The term camptocormia 
has been proposed by Souques and Rosanoff-Saloff. The 
poilus speak of the condition as cintrage (arching). In these 
cases the trunk is held almost horizontally, with the head in 
hypertension and neck muscles and thyroid cartilage jutting. 
The patient looks fixedly straight forward, with eyes wide 
open, and carries his legs extended or half flexed. The nor- 
mal folds of the abdominal wall are very deeply marked, and 
at the level of the groins, the epigastrium and the pubis, 
there are deep folds. Viewed from behind, the median 
lumbar fold has disappeared or is faintly marked, as are the 
sacro-lumbar and other masses of spinal muscles. The 
whole lumbar region is elongated and flattened. The dorsal 



shell-shock: nature and causes 341 

spines of the back are accentuated ; the buttocks are flattened 
and broadened transversely. The back of the neck is 
marked by deep transverse folds, and the seventh spine does 
not stand out. The patient can walk perfectly, though 
sometimes there is a pseudocoxalgia and lameness. At- 
tempts to straighten the body lead to visible forcible contrac- 
tions of various muscles, but the kyphosis remains persistent. 
There is a sense of active resistance on the part of the patient, 
which can be demonstrated by palpation. If an active 
attempt at straightening is made, lumbar or sacral pain 
develops, followed by a very lively and emotional state of 
anxiety on the part of the patient, with interrupted and 
accelerated breathing, an expression of terror in the face, and 
a rapid pulse. The patient then subsides into his earlier 
attitude, and his anxiety disappears in a few seconds. It is 
much easier in many subjects to reduce the camptocormia in 
the position of dorsal decubitus than upright. 



342 SHELL-SHOCK: NATURE AND CAUSES 



Burial after shell explosion; lumbar ecchymoses ; 
regionary pains ; camptocormia, $V 2 months. Cure 
by three months' plaster cast about trunk. 



Case 244. (Roussy and Lhermitte, 1917.) 

An infantryman was buried after shell explosion August 
25, 1 914, but he sustained no wound or bone injury. There 
was, however, a large ecchymosis of the lumbar region, and he 
had felt violent lumbar pains. The trunk was carried flexed, 
symmetrically bent over and quite incapable of being 
straightened completely. A plaster corset was applied March 
16 by Souques. Three months of this was followed by a 
complete straightening, which lasted after the corset was 
removed. The patient was discharged well. 

As to these cases of camptocormia, some authors regard 
them as due to anatomical changes in the vertebral column 
itself, or in the ligaments and muscles, and accordingly regard 
the condition as a form of spondylitis, syndesmitis, or psoitis. 
This view is held by Sicard, who bases the idea upon the 
local pains and the results of cerebrospinal fluid examination. 
According to Roussy and Lhermitte, hyperalbuminosis of the 
fluid is extremely rare, and one case of their own with hyperal- 
buminosis was nevertheless cured with great rapidity. 
Roussy and Lhermitte even inquire whether the fluid albumin 
may not be due in some way to an interference with venous 
and lymphatic circulation. 

In some cases, this condition may be at first a response to 
pain, a pseudospondylitis dolorosa, such as may be some- 
times observed in hospitals near the front. Later, however, 
the suffering in camptocormia is due more to the abnormal 
position of the trunk, with strain upon vertebral ligaments, 
than to the persistence of any original pain. Moreover, 
these patients recover almost immediately from their pains 
when the contraction is relieved. 

In differential diagnosis, one has to consider, according to 
Roussy and Lhermitte, Pott's disease, traumatic spondy- 
litis, as well as Bechterew's vertebral ankylosis, Pierre Marie's 



SHELL-SHOCK: NATURE AND CAUSES 34^ 

rhizomelic spondylosis, Kocher's intervertebral disc contu- 
sions, and Schuster's myogenic ankylosis of the vertebral 
column; but in Pott's disease, the fixed pain points, rigidity 
of column, fluid examination, and signs of myelitis, should 
suffice for the differential diagnosis. Traumatic spondylitis 
follows the contusion after months and after a phase of neu- 
ralgia. Ankyloses do not so much concern the trunk as the 
vertebral column itself; disc contusion produces disorders in 
standing and gait as well as pains and edema. Schuster's 
disease shows paresis, hyper reflexia, and amyotrophy not 
shown in camptocormia. 



344 SHELL-SHOCK: NATURE AND CAUSES 



Shell explosion; partial burial; forcible flexion of 
spine. Paraplegia, cured by suggestion. Then 
camptocormia, also cured. 



Case 245. (Joltrain, March, 1917.) 

An infantryman in the Cote du Poivre was sitting on the 
ground in the opening of a dugout eating soup, when a shell 
burst and the roof of the sap fell in on him. The planks and 
the stonework fell heavily on the dorsolumbar region. The 
patient was almost bent in two, head to knees, legs buried, 
hardly able to breathe. He did not lose consciousness and 
cried out, feeling for a moment very anxious and fearful that 
his comrades had left. Only two hours later was it possible 
to dig him out. He said he had been absolutely unable to 
make any movement, had kept his body bent, and felt violent 
pains in the back. He was carried back twelve hours later 
and reached the dressing station in eight more hours, eventu- 
ally reaching the neurological service two days and a half 
after the accident. On entrance he was prostrated, com- 
plained of lumbar pains and of inability to move, and was 
able to make only a few contractions on the left side when 
asked to try. The right leg was flaccid. The left knee-jerk 
was stronger than the right. Other reflexes normal. Hy- 
peresthesia to pin prick on the right side. Slight saddle 
hypesthesia, reaching to the iliac crests above and perineum 
below with preservation of touch sensation. Slight forward 
posture of vertebral column. The patient complained of 
pain on pressure of the spinal processes and the lumbar spine. 
There was slight ecchymosis about the left iliac crest. 

Lumbar puncture showed clear fluid without hypertension, 
in which were a few lymphocytes. There was a large amount 
of albumin. The blood pressure was normal. There had been 
a slight diarrhea following the accident which disappeared 
on entrance to the hospital. The question was raised whether 
the case was one of slight hematomyelia or was pithiatic. 

Suggestive therapy was tried, and liquid was injected into 
the muscles of the lumbar region and the posterior surfaces 



SHELL-SHOCK: NATURE AND CAUSES 345 

of the thighs. In a quarter of an hour the patient found him- 
self able to raise the foot above the bed. There remained an 
extensor paralysis of the right leg. When the patient was 
made to raise the foot he began to show the phenomenon of 
Souques, called camptocormia. He could walk, nevertheless, 
and took a few steps sustaining the weight of his body by 
placing his arms on his thighs. Though he complained of 
lumbar pain, it was finally possible for him to pick up an 
object from the ground and lean sidewise. He could not, 
however, stand up. Yet when the patient was made to lie 
down, his back was spontaneously straightened. Treatment 
of the camptocormia was also successful. 



346 SHELL-SHOCK: NATURE AND CAUSES 



Astasia-abasia : Two cases from (a) thigh wound, 
and (b) shell-shock and wound of thorax. Cures 
by faradism. 



Case 246. (Roussy and Lhermitte, 191 7.) 

An infantryman was wounded September 23, 19 14, by a 
bullet in the anterior and middle part of the left thigh. 
From the moment of the trauma, he had not been able to 
walk, but gradually regained his ability to stand, and then to 
walk. He was returned to the front (January, 191 5). 

Slightly wounded again in the neck, January 6, 1915, he 
was evacuated and operated on. After the operation he could 
neither walk nor stand. His reflexes were normal; he could 
perform all movements when lying down, although the move- 
ments were executed very slowly. As soon as he could sit 
upright, he was taken with tremors and could not hold him- 
self in a vertical standing position, nor take a single step. 
If he was given crutches, he dragged the two legs. 

Under the influence of electric treatment — a mild faradic 
current — he was cured at a sitting so that he could both 
stand and walk (March, 191 6) 

Case 247. (Roussy and Lhermitte, 1917.) 
Astasia-abasia after shell explosion occurred in an infantry- 
man observed by Roussy and Lhermitte at Villejuif, July 8, 

1915. 

The patient had been wounded September, 1914. The 
wound was a superficial one in the thoracic wall, under the 
right nipple. He had been cast into a very deep shell hole, 
but had been able to get back to the aid station alone, taking 
very short steps only. 

As soon as he reached the station, his gait became spastic, 
trembling and hesitant. Given two canes, he could walk 
painfully, trembling. At each step, he would balance his 
body back and forth. He gave the impression of a man 
drawing some sort of vehicle, who had to make a considerable 
effort at each step. 

The faradic treatment cured this patient at one sitting. 



SHELL-SHOCK: NATURE AND CAUSES 347 



War strain ; fall into water-filled trench : Dysbasia, 
tremors, vasomotor disorders. Cure by hypnosis. 
Case to demonstrate " traumatic " hysteria WITH- 
OUT somatic TRAUMA. 



Case 248. (Nonne, December, 191 5.) 

An artilleryman (without hereditary or acquired neuro- 
pathic taint) underwent much stress and strain in the war 
in Belgium, Lorraine and Flanders. One night, on leaving 
his observation post, he fell into a trench filled with water. 
He felt pricks in the groin and gradually developed a pseudo- 
spastic tremor of the lower extremity, paraparesis inferior, 
depression, irritability, pressure sensations in the head, and 
sleeplessness. He passed through three hospitals before 
arriving at Hamburg and received the diagnosis of concus- 
sion of the brain and cord. 

Nonne found an emotional state of depression with hypo- 
chondriacal fear, disturbance of sleep, deficient appetite, 
constipation and pollakisuria. He walked upon two crutches, 
dragging his legs inertly after him. There was marked cya- 
nosis, lowered temperature and hyperidrosis of the feet 
and lower legs; exaggeration of tendon and skin reflexes 
and pseudoclonus ; no Babinski or Oppenheim reaction. 
There was anesthesia of the lower extremities and of trunk as 
high as the ribs. Pulse 130. Visual fields normal. Sen- 
sory disorders absent. 

After the first hypnotic treatment the patient was able to 
stand and take a number of steps, and the tremor gradually 
diminished. After two treatments standing became normal 
and walking was much improved, the tremor ceased, cyanosis 
and hyperidrosis disappeared, and the movements of the 
bowels and urination became normal. Thereafter the pa- 
tient had no attention paid to him deliberately and in a 
week's time became well. 

Here is a case in which, as Nonne states, the somatic 
trauma required by Oppenheim as the basis of every trau- 
matic neurosis did not occur. Moreover, the sudden cures 



348 shell-shock: nature and causes 






by hypnotism, or by any other method in these cases, war- 
rant us in supposing that there are no such fine molecular 
changes as Oppenheim and von Sarbo assert. Such experi- 
ence as the cures in this group of cases confirms, according to 
Nonne, the surprising result first achieved in this war (Bon- 
hoeffer, Wagner von Jauregg, Karplus, Wollenberg, West- 
phal) that the most severe neuroses produced by somatic 
and psychic traumata can be cured in an astoundingly rapid 
manner without residuals. 

Re the controversy over Oppenheim's traumatic neurosis, 
Nonne holds with the Charcot school that traumatic neuro- 
sis is clinically identical with hysteria. Oppenheim admits 
the part played by psychogenesis, but has always laid a 
greater emphasis upon the actual injury of the neuronic 
apparatus in which he believes. He thinks that small hem- 
orrhages, inflammatory processes, and degenerative proc- 
esses affect the neurones unfavorably, and permit the psy- 
chogenic effects to occur more readily. Of course the in- 
surance-company attitude and the attitude of railway cor- 
porations saw malingering in all cases, and to this day, 
neurologists are inclined to see a great deal of "indemnity 
neurosis" in these cases. Opposed to the corporation men 
and the neurologists were the psychiatrists, who chiefly 
upheld an emotional theory of genesis — whence we began 
to hear of the neuroses of fright and of accident. 

Oppenheim claims to have established with war cases the 
fact that an entirely normal person without heredity and 
without antebellum acquired soil, may develop a neurosis 
through war stress. Oppenheim concedes that there may be 
purely psychic cases, but holds that there are nevertheless, 
numerous purely physical cases and a great number of cases 
of a compound nature, which are both physical and psy- 
chical in their etiology. Oppenheim's point is not that every 
single symptom described may not be upon occasion psycho- 
genic, but that the data of this war prove that neuronic 
injury, particularly injury of the peripheral neurones, can 
also produce these effects. Nonne, Forster, Lewandowsky, 
and others, opposed Oppenheim's views vehemently. See 
especially comments by Zeehandelaar. 



SHELL-SHOCK: NATURE AND CAUSES 349 



Shell-shock; BURIAL HEAD DOWN: Brachial 
monoplegia, head-shaking, speech disorder, corneal 
and conjunctival reflexes absent. Determination of 
hysterical phenomena to parts buried. 



Case 249. (Arinstein, 191 6.) 

A Russian private was buried after a shell explosion, 
September 13, 191 5, head down, so that only his legs stuck 
out of the debris. Afterward his right hand refused to move, 
and there was edema of the right wrist, with pain referred to 
the shoulder joint. The head shook and made jerky move- 
ments during the day, but ceased them in sleep. Speech was 
retarded; words were uttered clearly enough but in a sing- 
song fashion; sometimes the man stammered. Hearing was 
diminished in the right ear. Pupillary responses were lively, 
but the swallowing reflexes were diminished, and the corneal 
and conjunctival reflexes were absent. The tendon reflexes 
were lively on both sides. There were no pathological reflexes. 

At the end of October — six weeks later — the patient 
was sent home on convalescence for three months, and im- 
proved rapidly after a short time in family surroundings. 
He was examined again, two months after discharge, and 
found normal in all respects. He returned to the ranks. 

Re Shell-shock in Russians, Arinstein concludes that con- 
cussion hysteria may occur in a perfectly normal person, 
yet be innocent of all organic signs indicating destruction of 
peripheral or central neurones. Rifle or machine-gun fire 
had not in his experience brought about concussion hysteria, 
which was invariably due to the bursting of a large projectile. 
With reference to Schuster's remark that a sleeping man 
never acquires hysteria from the bursting of a shell near by, 
Arinstein confirms Schuster, finding amongst 2000 cases 
no instance in a soldier sleeping at the time the shell burst. 

Re effects of cannonading, Gerver reports Russian instances 
of a kind of hysterical clavus, or sensation of a nail being 
driven into the back of the head, in men who have been a 
number of days under stiff shelling. 



350 SHELL-SHOCK: NATURE AND CAUSES 



Multiple wounds and bullet wound of palm: ACRO- 
PARALYSIS. Cure, five months. 



Case 250. (Roussy and Lhermitte, 1917.) 

A patient was observed at Villejuif, February 5, 191 5. 
He had been wounded, January 2, 191 5, and showed scars of 
a bayonet wound on the anterior surface of the right thigh, 
of a lance wound on the dorsal surface of the right foot, and 
of a bullet wound in the palm of the left hand. 

There was left wrist drop with fingers extended. On the 
sensory side, there was a glove anesthesia and analgesia up 
to the bend of the elbow. The right leg showed a paresis 
and contracture, but there were no sensory disorders in the 
legs. Reflexes were normal. The patient was discharged 
cured, in May, 191 5 (psychoelectric method). 

This is an example of the so-called acroparalyses, paralyses 
limited to the hand or foot, many of which have developed 
in this war, after grazing wounds or more severe injury. 
More rarely they appear as if spontaneously. Sometimes 
they are preceded by slight arthralgia or vague pains. 

The condition in the hand suggests a radial paralysis. The 
patient is unable to flex his fingers, though he probably is 
able to make some movements with his thumb. Sometimes, 
on request to move the hand, a series of coarse oscillations 
follows, somewhat like a tremor. These oscillations are, 
according to Roussy and Lhermitte, apparently pathogno- 
monic, and depend upon the contraction of the muscles an- 
tagonistic to those whose movement has been requested. 
These antagonistic muscles, themselves entirely incapable 
of voluntary movement, are seen to be contracting effec- 
tively and jerkily to meet the action of the agonists, also 
seen making jerky movements. If the forearm is moved 
passively and rapidly, the hand flops about inert, like the 
hand of a marionette, although not to the degree of hypo- 
tonia in organic paralysis. The hand is often cold, moist, 
and cyanotic, and even possibly analgesic and hypesthetic. 



SHELL-SHOCK: NATURE AND CAUSES 35 1 



Bullet wound of arm: Apparent radial paralysis, 
not resolved by self-preservative swimming move- 
ments. Paralysis actually hysterical. 



Case 251. (Chartier, October, 1915.) 

A professional acrobat, 22, Corporal in an African Chasseur 
regiment, was rather instructively tattooed and had appar- 
ently performed some of his service in disciplinary companies. 
In short, one might have a legitimate suspicion of the ob- 
jective value of any manifestations he might present. How- 
ever, one of his chiefs had written a favorable letter concern- 
ing his services. He had had various crises of a hysterical 
character since adolescence, and there was alcoholism in 
the family. 

He was wounded May 4, 191 5, by a bullet which passed 
through the outer and lower part of the right upper arm, and 
thereafter the forearm and hand became completely inert, 
both for flexion and extension. There was a considerable 
hyperesthesia. The wound healed quickly, without compli- 
cations. 

August 5, about 10 o'clock at night, the man — then at 
his depot — tried to commit suicide (motive not related with 
the war). He threw himself into the Rhone from a height, 
where the water was deep and the current rapid. His 
brother and a comrade, who knew that he was going to make 
the attempt, saved him. Chartier himself happened to see 
the whole scene, and noted that throughout the affair the 
forearm and hand of the patient remained inert. It seemed 
as if there was a radial paralysis. This was the more likely 
as the man had been wounded in the arm. First care was 
given. The man had not known of Ch artier' s presence. He 
had been under water about two minutes. 

From hospital he was evacuated three weeks later with a 
diagnosis of radial paralysis, coming on service September 11. 
Examination showed a slight paralysis of the extensors and 
flexors of hand and fingers, and of the hand muscles. There 
was also a slight contracture of these muscles, more marked in 



352 SHELL-SHOCK: NATURE AND CAUSES 

the flexors. There was pain upon reduction, with some jerk- 
ing of the muscles. Electrical reactions proved normal in 
nerves and muscles. There was a segmentary anesthesia to 
pin prick, reaching to the level of the elbow; deep hyper- 
esthesia of the finger joints. There was no trophic or vaso- 
motor disorder. 

In short, here was a case of functional paralysis with con- 
tracture of the right hand, to be regarded as hysterical in 
the classical sense of the term, both by reason of the anes- 
thesia and absence of trophic disorder, and on account of 
the hysterical history of the patient. Functional reeducative 
treatment quickly improved the paralysis, so that two weeks 
later the patient was able to extend fingers and hand. His 
total recovery was hoped for, when, September 26, wishing to 
get out of the hospital without leave, the patient jumped 
from a window and broke his right leg. The functional 
paralysis of the hand persisted and even grew more marked. 

The interesting point in this case is that despite the power- 
ful nature of instinctive efforts with drowning persons, this 
patient, subject to an hysterical arm paralysis, did not make 
defensive movements with the paralyzed arm; yet this par- 
alysis was such as to be greatly improved by psychotherapy. 



shell-shock: nature and causes 353 



Bullet wound in brachial plexus region : SUPINA- 
TOR LONGUS CONTRACTURE, hysterical-look- 
ing. Callus of fractured rib probably at fault: 
Treatment surgical. 



Case 252. (Leri and Roger, October, 1915.) 

A man was wounded, December 21, 19 14, by a bullet which 
entered about the middle of the spinous process of the left 
scapula and was extracted a few days later from the pos- 
terior border of the sternocleidomastoid muscle, two finger- 
breadths from the left clavicle, that is, at about Erb's point. 
The left upper extremity was inert for ten days, but then 
began to move again, although extension and flexion of the 
fingers did not begin at once. 

October, 191 5, movements were normal, except those of 
extension of the forearm, due to contracture of the supinator 
longus muscle, a contracture that had developed about three 
weeks after the wound and stood out along the external 
border of the forearm, almost suggesting a musculotendinous 
retraction. There was a palpable, hard callus of a fractured 
rib, presumably a cause of the permanent irritation of the 
supinator longus, being precisely at the point where lesions 
usually produce superior brachial plexus palsy. 

Why should the supinator longus alone of the Duchenne- 
Erb group be affected? Perhaps a single root was involved in 
the irritative lesion. The biceps showed also a partial R. D. 
The deltoid was normal electrically and in contraction. 

The treatment planned for this case of isolated contrac- 
ture of the supinator longus was surgical operation of the 
irritative focus. According to Leri and Roger, it is sometimes 
dangerous to use such measures as massage and electric 
baths for a paralyzed limb, since the massage or electricity 
excite not only the affected muscles, but also the other sound 
muscles, — muscles that are already more powerful than the 
paralyzed muscles and may go into antagonistic contracture. 
Even in limited galvanization, it is desirable to work with 
weak currents, so as not to diffuse the current into non- 
paralyzed muscles. In case of radial or sciatic paralysis, 



354 SHELL-SHOCK: NATURE AND CAUSES 

apparatus permitting the extremities to rest without over- 
action of the muscles antagonistic to the paralyzed ones may 
well be applied. 

We here deal with a case, therefore, which looked purely 
functional, but in which careful examination and X-ray 
served to show an organic focus of irritation. 

Re nerve concussion, Tubby offers the following definition : 
Nerve concussion is damage to a nerve trunk without actual 
destruction of the axis cylinders. The damage may consist 
of an effusion of blood between the nerve fibres following 
compression of a nerve against the bone by rapid passage of 
a foreign body near the nerve. Sometimes, however, the 
lesion which causes damage to the nerve trunk without 
actual destruction to the axis cylinders is nothing more than 
a temporary anemia or hyperemia. In most instances, both 
motor and sensory function are together interfered with, but 
in the case of large nerve trunks, e.g., the popliteal, there 
may be a separate concussion of motor or sensory bundles. 



SHELL-SHOCK: NATURE AND CAUSES 355 



Contusion may effect a sort of STUPEFACTION OF 
MUSCLE and paralyze it by a non-psychic process : 
The SYNERGY in contraction of biceps and supina- 
tor longus is thus SPLIT. Biceps restored to 
synergy with the supinator by massage and f aradism. 



Case 253. (Tinel, June, 191 7.) 

A man was wounded at about the middle of his biceps and 
three weeks later was found to be able to flex the forearm only 
by means of the supinator longus. The biceps remained 
absolutely flaccid and soft, so that the diagnosis of a lesion 
of the musculocutaneous nerve (unlikely as this seemed on 
account of the low site of the wound) was entertained. 

However, the biceps and the musculocutaneous nerve 
proved electrically normal. In short, this paralysis of biceps 
was functional in nature. But, according to Tinel, there 
could be no voluntary suggestive or hysterical element in 
such a paralysis, since flexion of the forearm is normally 
produced by a synergic contraction of biceps and supinator 
longus that cannot be separated voluntarily. 

Treatment by massage and rhythmic faradization caused 
the biceps function to return to normal, so that voluntary 
synergic contractions of the biceps took place along with 
those of the supinator longus. 

We here deal, according to Tinel, with a genuine functional 
paralysis, nonhysterical — a paralysis due to a kind of stupor 
of the muscle. Such paralyses due to muscular stupor 
ought to get well in a few days or weeks. Should they per- 
sist, it is clear that a stuporous paralysis might be transformed 
into a hysterical paralysis. In short, the direct contusion of 
a muscle or group of muscles may be the point of departure 
for various persistent paralyses. 



356 shell-shock: nature and causes 



Wound of arm: Blocking of impulses to certain 
hand movements. Recovery with splint. 



Case 254. (Tubby, January, 191 5.) 

A private was wounded by a shell fragment, September 
16, 1914, and admitted to the London General Hospital, 
September 27. A high- velocity shell fragment had passed 
through the soft parts of the left arm at a spot exactly cor- 
responding to the musculospiral groove. He could extend 
the middle finger of the left hand, but the other fingers were 
held in flexion. The last two phalanges of index finger could 
not be moved, it was found, on account of severance of the 
extensor tendon some years previously. Accordingly, the 
loss of function due to the shell injury was that of thumb, 
ring, and little fingers. Supination could not be executed 
completely to the extent of 15 degrees; there was no R. D. 
upon electrical test, October 2. The sensation of affected 
fingers was woolly. November 3, the little finger had re- 
covered, but supination could not be completely executed. 

The treatment consisted in a bent malleable iron splint, 
with the wrist and affected fingers hyperextended. No- 
vember 20 all power had returned with full supination, except 
for the two phalanges of index finger previously injured. 

Major Tubby thinks this a case of physiological blocking, 
as from a small hemorrhage amongst the fibers or around the 
nerve. 

Re inhibition, Myers thinks it is the functional cause of the 
effects of shell-shock. He thinks it is not a fixation of the 
idea of the paralysis of volition, but that it is a fixation 
of the process of inhibition itself that produces the effects we 
see in Shell-shock. It is a block of ascending paths that 
produces the anaesthesia so characteristic of Shell-shock. It 
is a blocking of sensory paths that produces mutism or 
aphonia. But according to Myers, there is also a block in 
certain cases of descending paths that control and coordi- 
nate various mechanisms. The result of a block in the de- 
scending paths is shown in spastic, clonic, or ataxic phenom- 
ena of, e.g., functional dysarthria. See also Case 253 (Tinel). 



SHELL-SHOCK: NATURE AND CAUSES 357 



Eight months of war experience (often under heavy 
fire) without reaction; then, shell-shock; uncon- 
sciousness : Right hemiparesis ; pain in the left side 
of head ; heat sensations of right half of body ; dim- 
inution of hearing in left ear ; a variety of asymmet- 
rical bilateral phenomena. 



Case 255. (Gerver, 1915O 

A Russian private, 24, sustained shell-shock April 14, 191 5. 
He was observed, when the shell burst, to crouch down, and 
then to fall to the ground, unconscious. The unconscious- 
ness lasted about two days, after which he was found to be 
oriented, though slow and stammering of speech, hardly 
able to concentrate attention or sustain a conversation, and 
giving the impression of a man stunned. There was diffi- 
culty in the expression of thoughts, and a marked over- 
fatigueability. After adding and subtracting accurately two- 
digit figures for a time, the man quickly grew confused and 
said that trying to solve such a problem made him dizzy. 

His imagination was filled with gunshots, shell-bursts, and 
the killing of comrades, and during any conversation the man 
frequently shuddered. Concerning the shell-shock, he re- 
membered only that a number of shells had burst near him 
and that he came to in the hospital. He kept looking to one 
side and to a distance, as if listening, sometimes bending his 
head downwards. He would cry and sigh during conver- 
sation, and then be quite unable to explain why. He said 
there were loud noises in his ears, and that his head and the 
whole right side of his body felt hot. Pain was felt in the 
left side of the head. The right hand and the right foot were 
weak (on distraction, this hemiparesis remained unaltered). 
Tremors affected all the extremities. He had a sensation, 
possibly hallucinatory, of the creeping of insects on his skin. 
The hearing of the left ear was objectively diminished. 
There was palpitation of the heart and difficulty of breath- 
ing. Tendency to Romberg. There was a general hypal- 
gesia, more marked on the left side of the body. Both con- 



358 SHELL-SHOCK: NATURE AND CAUSES 

junctival reflexes were diminished. Knee-jerks and Achilles 
jerks were exaggerated. All the reflexes on the right side 
were livelier than on the left. There was a moderate Babinski 
reaction on the right side. Mechanical over-excitability of 
muscles. Dermatographia. Both sides of the skull were sen- 
sitive on tapping, but especially the left side. Mannkopf 
sign on pressure of the left side of the cranium. 

Hemorrhagic points without injury to the skin were noted 
on the skin of the left hand and foot. Speech was stammering. 
There was a marked digital tremor, sometimes spreading 
to the rest of the body during examination. The muscles 
of the face, eyelids, and tongue showed sharp fibrillary twitch- 
ing. The pulse stood at ioo and frequently missed beats. 
Battle hallucinations, visual and auditory, sometimes oc- 
curred, the commands of superiors and the noise of guns, 
rifles, yelling, and groans; the man would see trenches or 
redoubts, or a field full of wounded soldiers or attacking 
columns of the enemy. He recognized the hallucinations as 
such. His sleep was troubled by nightmares of the same 
general description. 

For eight months the man had been in action at the front, 
under heavy gun and rifle fire. He was a courageous man, 
who had never felt fear, regarding himself as used to battle 
and the bursting of shells. He had not been wounded. The 
entire situation seems to have developed after the single shell 
burst of April 14, 1915. 



SHELL-SHOCK: NATURE AND CAUSES 359 



LOCALIZATION OF SHELL-SHOCK SYMP- 
TOMS: Hemiparesis and hemianalgesia on side of 
body exposed to explosion; contralateral irritative 
symptoms of face and tongue. 



Case 256. (Oppenheim, January, 1915.) 

A soldier had a shell explode to his right, October 23, 
1 9 14. He declared that the concussion launched him through 
the air. When he recovered consciousness three hours later, 
he lay in a bog and was unable to move either leg. Gradual 
improvement followed. The symptoms were sensations of 
formication in the legs, pain in the back, blurred sight, 
hardness of hearing, disturbance of speech, headache, vertigo, 
weak memory. After a fortnight weakness in right arm. 

He was admitted to hospital a week after the injury, 
unable to walk, restless, given to palpitation and attacks of 
anxiety. On attempts to walk, leg spasms and tachycardia. 

Transferred to nerve hospital, December 2. Sleep poor, 
uneasy with dreams. Tic on left side of face. On opening 
the mouth, left- sided faciolingual spasm. Paresis of right 
arm. At first, right-sided ankle-clonus and paresis of leg. 
Knee-jerks increased. Speech hesitating. Right hemianal- 
gesia. Concentric contraction of visual fields. Tachycardia 
(120). In walking the right arm failed to swing normally. 
Attacks of vertigo, with falling. Patient got up at night and 
pushed against objects in his room. 

There was only slight improvement while under observa- 
tion. He became psychically more frank and even talka- 
tive, and was moving more readily when transferred. 

Re Oppenheim's conception of the strongly peripheral ele- 
ment in traumatic neurosis, he sums up by saying that a 
traumatism attacking the organism at its periphery is in 
line to produce a neurosis without any psychic mediation 
whatever. The r61e of the psychic process, in Oppenheim's 
view, is contributory to the fixation of neuroses. Even when 
there is a free interval betwixt shell burst and neurosis, still 
there are physical effects of trauma upon neurones. 



360 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; unconsciousness; after improvement 
in symptoms (4 months) return to trenches ; more 
symptoms after 5 days: Sensory disorders, espe- 
cially on left side (the side more exposed to explo- 
sion) ; exaggerated reflexes on right side with slight 
clonus and with Babinski sign. Improvement. 



Case 257. (Gerver, 1915.) 

A Russian Captain, 45 (heredity good ; non-alcoholic, non- 
syphilitic; always in good health) sustained shell-shock in a 
battle in southeastern Prussia, August 13, 19 14, and was 
unconscious for two days. He was carried to one of the 
provisional field hospitals, and then evacuated to Petrograd, 
where during a period of four months, he was given electric- 
ity, suggestion, and baths. He was feeling so much better 
in December, 19 14, that he went back to the front and headed 
his company in the trenches. He stood only five days of 
trench work, and was sent for mental examination December 
29, 1914. 

The captain was of middle height, well developed but 
poorly nourished, of a dejected and preoccupied appearance, 
looking to one side in conversation, and finding difficulty in 
the expression of his thoughts. He talked almost exclusively 
of his illness. He found difficulty in adding or subtracting 
2-digit figures. He seemed to have amentia, frequently being 
mistaken as to the most important dates in his life. He com- 
plained of general weakness and inability to work. Any 
endeavor to concentrate caused vertigo, irritation, and pains 
in the head. Day and night he was troubled about his health, 
his future, and his family's future. He was going to become 
an invalid and a burden. He was tormented with the idea 
that people thought him a simulator. He complained of 
lumbar pains. It seems that the explosion had affected the 
left side of the body more than the right and he complained 
more of pains upon that side. In the dark his gait was 
unsteady, and he often had marked tremors of feet and 
hands. In excitement the tremor would increase uncon- 
trollably. The patient thought that his hearing was di- 



SHELL-SHOCK: NATURE AND CAUSES 36 1 / 

minished, especially upon the left side, and that his left ear 
was weaker than the right. He slept poorly and had many 
nightmares; his appetite was poor, and he was constipated. 
There was difficulty in respiration; the pupils were slightly 
dilated and sluggish in their responses. There was a marked 
tendency to Rombergism; dermatographia marked ; the skull 
and especially the lumbar spine was painful on tapping; 
hyperesthesia of the lumbar skin; paresis of left hand and 
left foot. The tendon reflexes were more marked on the right 
side than on the left, and there was even a slight ankle and 
patellar clonus. The Babinski sign was present on the right 
side. There were frequent fibrillary contractions of the 
muscles of the trunk and back. 

Objectively the hearing was somewhat decreased in the 
left ear, and the vision of the left eye appeared to be somewhat 
impaired also. If the eyes had been held closed for a time, 
there was difficulty in opening them quickly. Aside from 
a somewhat elevated pulse and slight cardiac arrhythmia, 
there was no disorder of the internal organs. 

This patient remarkably improved but was not absolutely 
well at the date of the report. 

Re organic signs in Shell-shock cases, Oppenheim warns 
practitioners and experts against undervaluing war neu- 
roses. He does not like to have them set down in too off- 
hand a way, as hysteria, wish-fulfilment, and simulation. 
Hysteria is not likely, according to Oppenheim, in cases with 
permanent cyanosis, disappearance of the radial pulse, tro- 
phic disturbances, hyperidrosis, alopecia, fibrillary tremors, 
myokymia, cramps, dilated and sluggish pupils, and weak- 
ening of tendon reflexes. Hyperthyroidism also has been 
found by Oppenheim. 



362 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock, explosion on left side: Sensory dis- 
orders especially on left side; ecchymosis of right 
(uninjured) leg, possibly conditioned upon shock 
of left hemisphere. 



Case 258. (Gerver, 1915.) 

An artillery officer had had a shell burst to the left side of 
his horse, which veered to the right but did not fall. The 
officer's left hand immediately became so numb and weak 
that he could not hold his reins with it; it shortly became 
more painful. The left foot showed a tendency to the same 
anesthesia and paresis. 

Curiously enough, a number of punctate hemorrhages 
appeared on the right thigh and lower leg, upon the outer 
aspect. According to Gerver, these hemorrhages into the 
skin of the right leg may have something to do with a dis- 
turbance of circulation related with effects wrought upon the 
left hemisphere. During the course of the disease, pains 
occurred not only in the left arm and leg but also in the right 
leg. 

Re brain injuries produced by shell explosions without ex- 
ternal wound, Roussy and Boisseau have not found a single 
clinical instance amongst 133 cases observed, which sug- 
gested cerebral softening, or even hemorrhage into the brain 
substance, the cord substance, or the meninges. These 133 
cases were observed in army neurological centres and con- 
tained instances of (a) mental disease (confusion, delirium, 
amnesia), (b) nervous disease (astasia-abasia, tremors, pa- 
ralyses, contracture), and (c) an intermediary group (either 
mental confusion with stupor, or hysterical deaf mutism). 



SHELL-SHOCK: NATURE AND CAUSES 363 



K 



Shell-shock ; unconsciousness : Hysterical deafness, 
speech-disorder, gait. Recovery by reeducation. 
Brief relapse to deaf-mutism at noise of drums. 
Improvement. Relapse to numerous and severe 
hysterical symptoms at small guns fired on King's 
birthday. Improvement. Speech wholly regained 
in a quarrel. Recovery. 



Case 259. (Gaupp, March, 1915.) 

A musketeer, 22, had been blind for a time at 11 on account 
of some spinal cord disease. 

He was a soldier up to Christmas eve, 19 14, when he was 
hurled backward in a trench in the Argonne by an exploding 
hand grenade. He lay unconscious for several hours, though 
without sign of physical injury. Coming to his senses, he 
worked himself out of the trench and crawled to another, but 
again fell unconscious. When he awoke he was in a physi- 
cian's care in quarters, to which he had been taken by am- 
bulance men. Thence to the field hospital, and then to a 
private hospital at B. 

Upon admission, January 17, he was hard of hearing on 
both sides, and his speech was peculiar: choked off and 
retarded. His gait was heavy, on a broad base. He was 
subject to headaches. 

Exercises gradually improved the speech and the walking 
disorder was quickly overcome. February 5 came a relapse 
through fright at the rolling of drums near by. Speech was 
completely lost, deafness set in, and the patient ran restlessly 
to and fro in tears. After a few hours speech returned with 
still some minor difficulty. 

From time to time came fainting spells and attacks of 
disorder of consciousness, with loss of orientation and the 
idea of being in the trench or under cover. He would ask 
whether it were raining through. His mood herein was at 
times cheerful and excited. Speech further improved from 
the middle of February, as well as did the other symptoms. 



364 SHELL-SHOCK: NATURE AND CAUSES 

On the King's birthday, February 25, occurred another 
relapse due to his hearing small guns fired : Apathetic stupor, 
clonic spasm, aphonia, abasia, severe deafness, poor sleep, 
refusal of food. The next day he was still mute, but the 
spasms had ceased. He lay apathetically in bed, taking a 
little liquid food. February 27 he was still mute, though 
more active, not deaf, getting up alone, walking unsteadily 
on a broad base, and playing cards at the table. March 2 
the word yes was again enunciated. March 3 he talked more 
freely and took a short walk. March 4 speech of a sudden 
came completely back on the occasion of getting excited in a 
quarrel among some other patients. The patient thereafter 
began to talk a great deal, was bright and cheerful, but still 
complained of a variety of nervous troubles. Speech was 
somewhat difficult, but he was free from any definite aphasia 
or paraphasia. 

Re Shell-shock deafness, Jones Phillipson states that con- 
cussion deafness is due to three contributory factors: (a) 
cerebral concussion, (b) fatigue (violent oscillation of the 
perilymph, continued noises, strain of organ of Corti), and 
(c) temporary or permanent disorganization of the conductive 
apparatus. 

Re concussion deafness, J. S. and S. Fraser found in four 
cases of actual explosion injury, a ruptured drumhead and 
hemorrhage into the fundus of the internal meatus in three 
cases. They did not find evidence of neuro-epithelial changes. 
Possibly the fundus hemorrhages, besides giving rise to deaf- 
ness, may start up the tinnitus and giddiness that are some- 
times found. In one case, there were changes in the delicate 
nerve endings of the auditory ampullae. 



SHELL-SHOCK: NATURE AND CAUSES 365 



Shell-shock: Deafness 



Case 260. (Marriage, February, 1917.) 

A shell burst behind an English lieutenant in 19 14 without 
causing any wound but making him unconscious for an hour. 
During the hour the Germans passed by and stripped him 
of all articles of value. He came to and felt himself markedly 
deaf in both ears with an intense headache. There was no 
hemorrhage, no discharge, no tinnitus, no vertigo. Four 
days after the shell burst he could hear spoken words on each 
side at two feet, but could not hear a watch that could 
usually be heard from 3J to 4 feet. With tuning fork C air 
and bone conduction proved much subnormal, though air 
conduction was better than bone conduction. With tuning 
fork C-5 air conduction was subnormal. Drums healthy. 
Improvement followed; hearing became normal eighteen 
days after explosion. The treatment was rest in bed with 
bromides early and strychnine later. 

Marriage states that the psychical deafness due to shell- 
shock is usually bilateral and absolute. It is accompanied 
also, as a rule, by other nervous signs and symptoms, such 
as aphonia, tubular vision, paralyses, and anesthesias. 
Milligan and Westmacott state that the deafness is due to a 
functional suspension of neuronic impulses. They regard 
the brain as in a state of physical fatigue, and the mind as in 
a state of strain. There is no organic lesion. The neuronic 
impulses which are temporarily suspended are those which 
run from the higher cortical cells to the periphery. 



366 SHELL-SHOCK: NATURE AND CAUSES 



Mine-explosion : Unconsciousness : Deaf -mutism. 
Recovery of speech after epistaxis and fever. 



Case 261. (Liebault, October, 191 6.) 

A soldier, 24, teacher in civil life, was in a mine explosion 
November 27, 1914, at Vienne-le- Chateau. He was uncon- 
scious six weeks and remembered nothing of what had passed. 
They had told him that he had been blind for a month. After 
regaining consciousness he was a deaf-mute and for seven 
months he did not speak. His mutism did not bother him, 
as he thought he had always been mute. He had always been 
able to write. He could not remember what had interfered 
with his speech or tell whether he could think the words 
which he could not utter. 

May 22, 1915, there was considerable nasal hemorrhage, 
with fever. Upon this day he began to speak, at first a few 
words, telegram style, and with aphonia. A week later his 
voice returned. He was very irritable during the period of 
mutism and had ideas of persecution and of suicide and com- 
plained of becoming easily fatigued and exhausted. 

His voice, however, became completely normal again and 
his respiration better. On the spirometer he breathed four 
liters, but still got out of breath easily. His diaphragmatic 
respiration was still imperfect. His deafness remained at 
the time of report about as before, though he had now been 
hearing for some time a slight resonance of his own voice and 
could hear sounds emitted a few centimeters from his ear. 
At time of report there was still general fatigue with insomnia. 

Re war deafness, Castex states that not merely shell 
bursts and explosions are able to cause deafness, but the 
din of battle alone. There are two big groups of war deaf- 
ness: one due to drum rupture, and the other due to laby- 
rinthine shock. Labyrinthine shock — a much more serious 
matter — is produced when a big shell bursts. In these 
cases, the labyrinthine disorder is simply of the same general 
nature as commotio cerebri. The labyrinthine shock cases 
often need to be retired permanently from the front. 



SHELL-SHOCK: NATURE AND CAUSES 367 



Shell-shock : Deaf-mutism. 



Case 262. (Mott, January, 1916.) 

A deaf-mute, 24, not of a neurotic temperament or of a 
neuropathic predisposition, was admitted to the Fourth 
London General Hospital November 16, 191 5. 

He wrote, "I left England the 8th of March, and went to 
Gallipoli on the 26th of May, and about the middle of August, 
one of our monitors fired short. I felt something go in my 
head; then I went to the Canada Hospital. They said it 
was concussion." He had seen the monitors firing. He 
came to in a dug-out about an hour afterward. He was quite 
deaf and his head felt as if it would burst. 

He could see and speak a little but lost his speech com- 
pletely when Barany's tests were applied. The headache 
then passed away, leaving the deaf-mutism. The ears, on 
examination, proved normal. The patient was able to cough 
and whistle. He wrote his wife a letter, telling her how he 
killed a Turkish woman sniper, but he did not remember that 
he had written the letter. Although he said he did not dream, 
while asleep he would assume the attitude of shooting with a 
rifle, as if pulling a trigger, and then the attitude of using the 
bayonet: the right parry, the left parry, and the thrust. 
Sometimes while asleep he would jump as if a shell were 
coming, and he would catch his right elbow as if hit there. 
He would then open his eyes wide and look under the bed. 
Then he would wake up and begin to cry, but without sound. 
Just such habitual attitudes occur in soldiers under anesthesia. 
In hypnotic sleep, although he trembled at his trench experi- 
ences, he did not assume these defensive attitudes. 

Mott states in his Lettsomian lectures that hearing is 
often absolutely lost, but that sometimes a man is absolutely 
deaf on one side alone, either from the ruptured drum or 
from the violence with which wax has been driven against 
the drum. Mott speaks of the frequency of auditory hallu- 
cinations, and of hyperacusis — part of the patient's general 
hypersensitivity — which may increase the violence of the 
neurosis and especially aggravate the headache. 



368 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock : Deaf -mutism ; convulsions and dream. 



Case 263. (Myers, September, 1916.) 

A private, 28, was seen by Lt. Col. Myers at a base hospital. 
This deaf-mute wrote, "I was standing and a shell bursted 
and that is all I can remember." This might have happened 
six days previously. The patient wrote vaguely about a 
walk to "windy corner"; about being billeted in a dug-out, 
a train journey, and another hospital. He was deaf, deficient 
in sensibility throughout, especially in the left arm and left 
side of the face, and had severe headache. Two days later 
he started distinctly when hands were clapped while he was 
writing, but at the next hand-clapping there was no response. 

After Lt. Col. Myers wrote down, "Imitate me," and made 
consonant sounds, the patient succeeded imitating them. 
"You hear me a little now," Lt. Col. Myers wrote. "Is this 
the first time you have spoken? " Patient replied, "I hope 
the Lord I can get my speech." "But you did speak just 
now. Read this word. Say it." Whereupon he was got 
to say his name and number. 

The therapy was proceeding properly when suddenly he 
was seized with convulsions, limb movements chiefly clonic, 
back arched, eyes starting, later upturned. The patient 
pulled out a crucifix from a locker near the bed and regarded 
it ecstatically (pulse 85, corneal reflexes preserved). Three 
minutes later there was quieting down, and the patient was 
induced to talk. He began to talk about his wife. He had 
just been "seeing a farm and all the fighting." A shell must 
have come in there. He had "seen the Lord Who saved 
him." Intense headache and thirst followed. According to 
the patient the excitement was due to recovery of speech. 

He later said, "It was just like a dream when I came to. 
I was sweating awful. I was seeing the Lord while I was in 
the farm by the Captain. I dreamed that I had the cross in 
my hand to meet him coming. I saw the trenches and the 
dug-outs and the wife." In point of fact, the Captain at the 



SHELL-SHOCK: NATURE AND CAUSES 369 

farm had had his arm blown off, and he had found him lying 
on the straw unconscious. Under hypnosis it appeared that 
he had gone to a dugout from the farm and that at the 
clearing station he had been "raving, seeing things, shells, 
trenches, and things like that, sir." A slow recovery was 
made after evacuation to England. Seven months later he 
returned to the front. 

This case appears to belong to the B group of mutism 
cases, according to the classification of Myers, namely, 
to the group in which the effects are psychical rather 
than physical. According to Myers, whether mutism 
occurs as an apparent result of physicochemical or of 
mental causes — that is, as an A or a B case — it is 
actually always the result of mental — that is, psycho- 
physiological shock. Mutism in the A cases of physical 
nature, where the shock must have been grosser and 
more profound, generally proves more severe than in 
the B cases. As to the appearance of unconsciousness, 
apparently confirmed by the patients' statements that 
they "lost consciousness," it is a question whether these 
cases are not really cases of deep stupor. According 
to Myers, the mutism is in nearly every instance 
closely dependent on some form of stupor, being 
generally the relic of such stupor after it has passed off. 
Let the loss of consciousness be a profound stupor due 
to the lifting or burial of the patient, then from this 
stage there will be a transition to a state of ordinary 
stupor in which intelligence is active but the patient 
is unresponsive to stimuli. The patient is in a condi- 
tion called by Myers excommunication, in which the 
inhibitory process may be regarded as protecting the 
individual against further shock. As the stupor now 
passes away, it is natural that the inhibition should 
appear lost in the case of hearing and speech, which are 
two main channels of intercourse with others. 

Dumbness is, by far, the commonest disorder of 
speech, occurring in about ten per cent of shock cases 
in the first thousand cases of shell-shock seen by Lt. 
Col. Myers. Stuttering and jerky speech have occurred 
in about three per cent. Loss of voice is rarer. 

As against the view of Babinski, that mutism, being 
curable by suggestion, must have been produced by 
suggestion, Lt. Col. Myers argues that the stupor pre- 
ceding mutism is the antithesis of suggestibility and is, 
in fact, a condition of extreme autofixity. 



370 shell-shock: nature and causes 



Naval gun-fire effects on seaman : Aphonia. Two 
recurrences. 



Case 264. (Blassig, June, 191 5.) 

A seaman from the Derfflinger was brought into a naval 
hospital with loss of voice, December 22, 19 14, able to speak 
only in a whisper. As a child he had had diphtheria, but 
recovered without complication. He had always had a very 
well-controlled voice. Early in December he had had a cold 
owing to sentry deck duty in bad weather. Two days after 
the shelling of Scarboro, — December 16, — while in the 
munition chamber of the big guns, he suddenly lost his voice. 
He had been greatly upset during the firing of the guns. In 
two weeks he recovered speech. 

February 12, 191 5, he returned to the hospital with a 
complete aphonia. This was immediately after the naval 
engagement in the North Sea. Three days later he was 
treated with electricity directly applied to the vocal cords. 
March 20 he was discharged with speech completely recovered. 
As soon as he went on leave, however, his voice was lost for 
the third time, and he was still aphonic at time of report. 



Shell-shock MUTES observed, then DREAMED 
OF: MUTISM developed the SECOND NIGHT 
after shell explosion. 



Case 265. (Mann, June, 1915.) 

A volunteer of 20 was made unconscious for a short time 
by a shell explosion, but was still fully able to speak when 
brought to the field hospital. 

In the second night after the explosion, however, he 
dreamed that he had lost his speech. In the ward, mean- 
time, he had seen a number of shell-shock mutes. Following 
this dream of aphasia, came several weeks of mutism, which 
then cleared up. According to Mann, this is experimental 
proof of the psychogenic origin of a mutism. 



SHELL-SHOCK: NATURE AND CAUSES 37 1 



Mortar explosion : Hysterical deafness. 



Case 266. (Lattes and Goria, March, 1917.) 
A young soldier, a peasant, fell down unconscious when a 
mortar exploded killing several men. He regained con- 
sciousness a few hours later but was deaf on both sides. He 
looked dazed and did not spontaneously move, having to be 
called for meals. Communicating by writing, he could tell 
all the details of the accident. 

The laryngeal and corneal reflexes were absent and there 
was a hyperesthesia and hypalgesia of the right side of the 
body. No anatomical basis for the deafness could be deter- 
mined. 



Shell explosion : Onomatopoeic noises in ears. 



Case 267. (Ballet, 1914.) 

A Zouave was with his squad at Tracy-les-Val Church, 
October, 1914, when the roof was burst in by a shell which 
wounded four men. The Zouave felt a strange emotion with 
trembling, and whistling in his ears. However, he helped 
his comrades into a neighboring car. From that time for- 
ward, he was very emotional, and felt noises in his ear, some- 
times humming, sometimes whistling. At Compiegne Hos- 
pital a lumbar puncture was made, perhaps with a thera- 
peutic purpose, but this gave no results. The noises were 
heard as a whistling pseeee followed by a boom, — an ono- 
matopoeia recalling the whistling and bursting of the bomb. 
There was, in short, no labyrinthine lesion, but merely an 
obsessive mental phenomenon. There were no ear lesions 
objectively. The man developed a stuttering some time 
after the humming and whistling in the ear. 



372 SHELL-SHOCK: NATURE AND CAUSES 



Injury of eyes by gravel from shell-burst : Photo- 
phobia, blespharospasm, facial anesthesia, pains. 



Case 268. (Ginestous, January, 191 6.) 

A soldier of the Ninth Engineers, 28, a Beaux- Arts student, 
was wounded, December 19, 191 5, by stones and gravel thrown 
in his eyes by a shell-burst. The eyelids swelled and the eyes 
filled with tears. He was treated at the relief station and 
then evacuated to Verdun. The edema disappeared in five 
weeks, but it was impossible for him to look at light. Febru- 
ary 2 he was evacuated to Nice, where he received the diag- 
nosis of traumatic keratalgia, blepharospasm, and photo- 
phobia. After eight days' leave he went back to his corps; 
but the eye troubles persisted and he was sent to the ophthal- 
mological center at Angers, May 18, 191 5. 

Both his father, 67, and his mother, 58, were irritable and 
odd. Three brothers and three sisters were also more or less 
neuropathic, and one of the sisters had been in a hospital for 
the insane with a persecutory mania. The patient had a 
daughter, fourteen months, well. 

The man was a nervous, impressionable person, who wept 
at the slightest emotion. With an effort of will he could 
open his eyes, but if one tried to open them passively there 
was stout resistance. In the dark the occlusion was not so 
complete. Both eyelids were wrinkled and folded and made 
jerky, fibrillary movements. The conjunctiva and cornea 
were normal (fluorescein test), but the palpebral conjunctiva 
was red and injected. The patient said he had subcutaneous 
pains recurring at irregular intervals above and below the 
left orbit, brought out or exaggerated by pressure; but such 
pressure had no effect upon the lid movements. Visual 
acuity was normal, but the use of ophthalmometer was 
impossible, as was measurement of the visual field. There 
seemed to be no disorder of chromatic sense. The reflexes 
could not be fully examined; knee-jerks preserved. There 
was a zone of anesthesia to pin prick, less marked to heat, 
on the whole left side of the face. W. R. negative. 



SHELL-SHOCK: NATURE AND CAUSES 373 



Shell-shock ; burial ; blow on occiput : Blindness. 



Case 269. (Greenlees, February, 1916.) 

A man in the third Wiltshire regiment was buried in a shell 
explosion and struck by a large mass of earth on the back of 
the head. When dug out, he was found blind. It was 
thought at the time that the severe blow at the back of the 
head had "concussed " the occipital cells for sight. 

Some months later the man was sent to Mr. Pearson's 
home for blind soldiers in London; but two months later was 
returned to Weymouth, under Greenlees' charge. He thought 
himself worse, since now he could not see light at all. He 
had trained himself to take care of himself and steered con- 
fidently aside from obstacles in walking about. He was able 
even to learn the various colors by the sense of touch, accord- 
ing to Greenlees; thus, blue was diagnosticated against red: 
according to the patient, a piece of colored card always had a 
rougher feel if it was blue than if it was red. In fact, his work 
consisted of making colored net bags. 

As to the possible interpretation of such a case, see Case 
No. (man who could see large letters sometimes). 

Re blindness, H. Campbell states that the number of cases 
of hysterical blindness appears to be decreasing as the war 
continues. The blindness he finds to be rarely an absolute 
one. As a rule, the vision is merely blurred or there is a 
contraction of the visual fields. The condition is much less 
frequent than that of deaf mutism. 

Re hysterical blindness, Dieufaloy is cited by Crouzon as 
describing a triad of conditions characteristic of hysterical 
blindness, namely, (a) sudden onset, (b) preservation of pupil- 
ary reflexes, and (c) normal fundus. 



374 SHELL-SHOCK: NATURE AND CAUSES 






Shell-shock amblyopia (composite data). 



Case 270. (Parsons, May 191 5.) 

Parsons describes a typical case of shell explosion ambly- 
opia. After more or less prolonged fatigue from marching 
and trench exposure, the soldier is knocked down or blown into 
the air, and more or less severely injured or wounded by 
concussion, fracture, bullets, or shell splinters, losing con- 
sciousness, but perhaps not enough to prevent automatic 
walking in a dazed state to the dressing station. Memory 
of this phase is lost. The man is instantaneously stricken 
blind, possibly also deaf; and possibly smell and taste are 
also lost. Blepharospasm is intense; there is lacrimation; 
the lids are opened with such difficulty that examination of 
the eyes is almost impossible (nor, according to Parsons, 
have the pupils yet been examined at this stage). 

In a week or two the blepharospasm diminishes, and the 
fundi, which are found to be absolutely normal, can be 
examined. The eyes may be found to be quite normal, the 
pupils reactive to light though perhaps sluggishly and per- 
haps unequally. Sight is now somewhat restored, light can 
be perceived, and large objects distinguished. The patient 
can grope about and usually does not stumble against ob- 
stacles. The fields of vision are markedly contracted, and 
more so than the avoidance of obstacles in walking would 
suggest. 

Vision is eventually recovered completely. The right eye 
(the shooting eye) is often more deeply affected and recovers 
more slowly. Perhaps a central scotoma may persist. 
Sometimes on manipulation of lenses the full vision can be 
produced for the types. Parsons seeks to explain the psy- 
chology of traumatic amblyopia in the light of deductions of 
Lloyd Morgan, Mark Baldwin and McDougall. 



SHELL-SHOCK: NATURE AND CAUSES 375 



Shell-shock amblyopia (excitement, blinding 
flashes, fear, disgust, fatigue). 



Case 271. (Pemberton, May, 1915.) 

Pemberton calls attention to the following factors in a case 
of amblyopia: First, excitement during a prolonged and some- 
what critical attack; second, overstimulation of eyes and 
ears due to brilliant flashes, night firing from many batteries 
close together (the gunners are always subject to temporary 
deafness from this firing) ; third, natural fear from close burst- 
ing of shells; fourth, disgust at decapitated and disem- 
boweled soldiers; fifth, fatigue from twelve hours' work. 

The artillery sergeant worked under heavy shell fire at 
Gun No. I. A direct hit killed three men serving No. 2 gun. 
The sergeant became somewhat excited but worked his gun 
until the following dawn, when he collapsed across one of the 
disemboweled corpses. He thus had been at work for about 
twelve hours. The battery had fired 400 or 500 rounds. 

A few hours later, the man was conscious but very feeble 
and much shaken. There was amblyopia and contraction 
of the fields of vision to rough tests, but no change in color 
vision. Taste sense was blunted, and salt could hardly be 
told from powdered quinin tablets. Smell also was practi- 
cally absent, although he had never been able to smell 
accurately. Hearing was not more affected than that of 
other men in the battery, and there were no tympanic frac- 
tures. Both thighs, from about the apex of Scarpa's triangle 
to the knee, showed partial anesthesia, such that a pin prick 
that should have been painful was felt only as a tactile sen- 
sation, whereas lighter stimulation caused no sensation what- 
ever. The patient himself complained of numbness in these 
areas. The gait was slow and spastic. The knee-jerks were 
brisk. Sent back to the wagon lines for a week, the patient 
lost his sensory disturbance, but the symptoms of mental dis- 
tress increased. He walked weakly and stiffly; he continu- 
ally thought of the dead men at the next gun, one of whom 
was a friend. He was finally sent to a hospital in England. 



37^ SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock amblyopia. 



Case 272. (Myers, February, 191 5.) 

A private, 20, lay in the booking-hall of a station, October 
28-29, not securing much sleep; motored in a bus next day 
to another place at 7.30 p.m.; went into billets at 8 p.m.; 
mounted guard 10-11.30 p.m. and 1.45 to 3.45 a.m.; and 
went to the firing-line for the first time at 11 a.m. October 31. 
The platoon advanced through two sets of trenches, which 
were full, and had to retire. About 1.30 p.m. they were found 
by the German artillery. 

This man had been rather enjoying it and was in the best 
of spirits until the shells began to burst. The platoon was 
retiring over open ground. He was kneeling on both knees, 
trying to creep under wire entanglements, when two or three 
shells burst near by. Three more shells burst behind and 
one in front. The escape was described by an eye-witness 
as a miracle. He managed to get back under the entangle- 
ments and into the trench, and shortly, as the fire slackened, 
rejoined his company. 

His sight had become blurred immediately after the shell 
burst. Opening his eyes hurt him, and the eyes burned when 
closed. The right eye " caught it " more than the left. At 
the same time, he was seized with shivering, and cold sweat 
broke out, especially about the loins. He thought the shell 
behind caused the greater shock, like a punch on the head 
without pain. The shell that burst in front had cut his 
haversack away, bruised his side, and burned his little finger. 
This shell he thought caused his blindness. 

He was led to the dressing station by two comrades, open- 
ing his eyes to see where he was going but finding everything 
blurred except immediately after opening his eyes. There 
was no diplopia. Objects seemed to dissolve. He was 
weeping and worrying about becoming blind. The horse 
ambulance took him to a hospital and thence to another 
hospital, and thence he went by motor ambulance at night 
to the starting point, where he arrived five days after he had 
entered the field. He could remember nothing about the 



SHELL-SHOCK: NATURE AND CAUSES 377 

ambulance trips. There was a slight deafness which soon 
passed off. In hospital he shivered almost incessantly in 
bed, and he kept thinking about his experience and the shell 
bursting. The shivering ceased November 3. No micturi- 
tion from the afternoon of October 30 until the afternoon of 
November 2. No movements of bowels from October 30 to 
November 5. 

It seems that this soldier had been for two months in the 
Aisne district, sleeping badly on account of lumbar pains and 
toothache. There had been albuminuria, and the patient 
said he had failed to pass a medical examination. The fields 
of vision were found to be distinctly contracted. There was 
difficulty in taste and smell, which the patient said he had 
lost since the shell-burst. 

Hypnosis was tried but the patient "insisted on resisting/' 
The suggestions were offered during the concentration 
period. November 13 taste and smell began to return and 
the fields of vision were less contracted. He was transferred 
to England for further treatment, and by November 27 had 
become much improved and not so "nervy." February 1 he 
had begun to attend hospital as an out-patient. 



378 SHELL-SHOCK: NATURE AND CAUSES 



SHELL WINDAGE (NO EXPLOSION) : Multiple 
affection of cranial nerves. 






Case 273. (Pachantoni, April, 1917.) 

August 22, 1 914, a French officer was leading his company 
to an attack and carried on, though wounded in the side by a 
bullet. Suddenly he felt as if he had received a terrible blow 
with a hammer on the left cheek and eye and as if his arm 
had been torn off. He fell to his knees without losing con- 
sciousness. There had been no explosion, and none of his 
soldiers had been hit. He felt of his arm and carried his 
hand to his head to make sure of the wounds. There were 
none, but he was bleeding from the nose and the mouth. 
His left eye was closed and his left cheek drawn "by an in- 
visible hand." His tongue had swollen until it had to be 
pushed out of his mouth. He was breathing hard. He fell 
upon his side without losing consciousness and he was carried 
by his men to shelter in a trench. Placed on his back he felt 
that he could not lift his head as "it had become too heavy." 
His voice was lost. He could neither cough nor spit. In 
order to get air he had to remove bloody saliva from his 
mouth with his finger. The left side of the head was swollen. 
On opening his eyes he could no longer see with the left eye. 
His cheek was covered with ecchymoses but without wound. 
A few hours later he was made prisoner by the Germans. 
For two months he had an increase of temperature every 
evening and for three months he lost his voice. Six months 
later there was still visual impairment. He was anesthetic 
in the left cheek, unable to chew, paralyzed in the left facialis 
region. There was alteration of taste, with atrophy of the 
left side of the tongue deviating to the paralyzed side, and 
nasal regurgitation. There was continual drooling and con- 
vulsive coughing. In dorsal decubitus the head could be 
lifted with difficulty. There was a kind of paresis of the 
esophagus, as he felt the bolus stop at the level of the third 
ribs so that with each mouthful he had to swallow a little 
water. Apparently he had a paralytic state of the following 



SHELL-SHOCK: NATURE AND CAUSES 379 

nerves: optic, oculomotor, trigeminal, glossopharyngeal, 
pneumogastric, spinal accessory and hypoglossal. There was 
evidence of a slight old tuberculosis at apices. The man was 
slightly pale. There was an atrophy of the optic nerve and 
some retinal swelling. No pupillary reactions to light on the 
left side; but the accommodation reflex and sensory reaction 
were preserved. Divergent strabismus of the left eye. The 
taste on the left side and on the anterior part of the tongue 
was slightly diminished. Diminution of galvanic and faradic 
excitability on the left side of the face. No reaction of 
degeneration. Bitter, salt and sweet tastes altered. Left- 
sided atrophy of the tongue. No reaction of degeneration 
in the tongue and thyroid muscles although there was a 
marked diminution in faradic excitability. 

The author records this case of multiple lesions of cranial 
nerves as due to shell windage. Thirty-one months after the 
onset of the paralysis the cranial nerves, although manifestly 
regenerated, had not regained conductivity. The officer was 
examined by Pachantoni at Loueche-les-Bains in Switzerland. 

Re windage, see remarks under Case 201. 



380 SHELL-SHOCK: NATURE AND CAUSES 



Wound of thigh : Claudication, vasomotor disorder, 
hypothermia, but no exaggeration of tendon re- 
flexes. Under CHLOROFORM, ELECTIVE EX- 
AGGERATION OF REFLEXES, i.e., in this case, 
hyperreflexia of affected thigh, including patellar 
clonus, after other reflexes (including conjunctival) 
had become extinct. The case described led to 
the new formula of THE PHYSIOPATHIC SYN- 
DROME (BABINSKI). 



Case 274. (Babinski and Froment, 191 7.) 
Babinski examined in August, 191 5, at the Pitie, a soldier 
who had been wounded in the upper and outer part of the 
thigh. He showed a most marked claudication with outward 
rotation of the foot. There was a muscular atrophy of the 
thigh but no appreciable disorder of the electrical reactions. 
There was a slight limitation in the movements of the hip, 
namely, the movements of flexion and internal rotation of 
the thigh upon the pelvis; yet this limitation of movements 
did not seem to be in proportion to the rest of the motor 
disorder. The X-ray showed no joint lesion. The right 
knee-jerk was a bit stronger than the left, though this was 
controversial. Achilles reflexes were normal and equal ; epi- 
leptoid trepidation of the foot, and clonus of the patella 
absent; the limb showed marked and permanent vasomotor 
disorders and local hypothermia; both phenomena were of a 
sharp and definite nature. 

On the basis of the intensity of these vasomotor disorders, 
Babinski felt that, in accordance with his general ideas, he 
was not dealing with hysteria, and that he was in fact dealing 
with the so-called physiopathic syndrome. Lacking for this 
syndrome was the exaggeration of the tendon reflexes of the 
affected limb. Might it not be that the improper attitude 
and muscular stiffness of the limb were based simply on re- 
tractions of tendons? The patient was chloroformed. This 
procedure was the more warrantable as a number of phy- 
sicians had thought of the patient as an exaggerator or 



SHELL-SHOCK: NATURE AND CAUSES 38 1 

even as a simulator. Under chloroform there was in fact 
a slight tendon retraction; yet on the whole it was clear that 
the attitude and stiffness of the limb were largely dependent 
upon a contracture. When during narcosis all the other 
tendon reflexes and skin reflexes had become extinct, there 
was still to be observed on the affected side a hyperreflexia, 
and even a clonus of the patella; and the clonus lasted an 
hour after recovery from the anesthetic. This curious 
phenomenon of elective exaggeration of tendon reflexes in 
narcosis, Babinski has observed to be not infrequent. It is 
a valuable diagnostic sign for a sure proof of excess tendon 
reflexes in cases where doubt prevails under ordinary cir- 
cumstances. Sometimes the contracture will yield, but only 
in the deepest sleep, outlasting even the conjunctival reflex 
and the reactions to pricking of the normal extremities. 
Moreover, the contracture would return from 20 to 25 minutes 
before any manifestation of consciousness. If an endeavor 
was made to reduce the contracture under full anesthesia and 
in complete unconsciousness, a spasmodic movement was 
provoked which exaggerated the abnormal attitude of the 
limb. Sometimes even the leg would be thrown into flexor 
contracture. 

The case above described was the one which led Babinski 
to his new formula of the Physiopathic Syndrome. This 
he describes in general terms as follows: 

These disorders consist in post-traumatic contractures, 
paralyses or paretic states, but are not attended by any of 
the signs of the so-called organic diseases, either of lesions of 
the central nervous system, or of the peripheral nervous 
system, or of the great arterial systems. In fact, these dis- 
orders somewhat resemble hysterical manifestations. The 
underlying lesions appear to be sometimes extremely small; 
in fact, so minimal as to be out of proportion with the func- 
tional disorders that they produce. These disorders do not 
correspond with any known anatomical regions, but they are 
singularly tenacious, and, unlike truly hysterical (pithiatic) 
phenomena, they are completely resistant to suggestion. Yet 
it is not merely in resistance to suggestive therapy that 
these reflex disorders differ from hysteria; for besides the 



382 SHELL-SHOCK: NATURE AND CAUSES 

contracture and the paralysis or paresis found in the different 
segments of the extremity concerned, the complete Babinski 
syndrome includes also muscular atrophy, exaggeration of 
tendon reflexes, alterations of skin reflexes (even amounting 
to areflexia), hypotonia, mechanical over-excitability of the 
muscles with retardation of the muscular contraction; 
quantitative changes in electrical excitability of muscles 
(excess or diminution without R. D.), mechanical over- 
excitability, and occasionally electrical over-excitability of 
the nerves, disturbances in objective and subjective sensi- 
bilities (anesthesia and pains), heat regulation disorders 
(especially hyperthermia), and disorder of the vasomotors 
(cyanosis, skin redness, oscillometric lowering at the periph- 
ery of the extremity in the presence of low temperature), 
secretory disorders, and various trophic disorders of the bony 
system, the skin, and the nails. 

Despite the permutations and combinations of these 
symptoms, according to Babinski they amount to a new 
group of disorders and represent a nosological species: a 
species of disease phenomena that lies midway between the 
organic affections and hysterical disorders. Babinski pro- 
poses the term physiopathic for these phenomena, a term 
which excludes the connotation of hysteria and all forms of 
psychopathia, on the one hand, and seems, on the other, to 
express the fact of their correspondence to a physical material 
perturbation in the nervous system of a novel sort. 






SHELL-SHOCK: NATURE AND CAUSES 383 



Bullet wound of ankle : Contracture effect of chloro- 
form. 



Case 275. (Babinski and Froment, 191 7.) 
A man was wounded, September 1, 1914, by a bullet in the 
left ankle. Contracture of the foot and of the four outer toes 
in extension followed, with a flaccid paralysis of the great toe. 
The left knee-jerk was a little stronger than the right; the 
left Achilles jerk also appeared weaker but observation was 
difficult on account of contracture of the foot. 

Chloroformed, October 22, 191 5: There was no sharply 
defined asymmetry of the tendon reflexes. The left Achilles 
reflex appeared a little weaker. In the phase of muscular 
resolution, the contracture disappeared entirely, but it re- 
appeared a little after the return of the tendon reflexes. The 
reappearance of the contracture preceded the reappearance 
of consciousness from twenty to twenty-five minutes. 






384 SHELL-SHOCK: NATURE AND CAUSES 



Post-typhoidal reflex or physiopathic disorder of 
right leg. Elective exaggeration under chloroform. 



Case 276. (Babinski and Froment, 1917.) 

A typhoid patient, October 20, 19 14, showed phlebitis and 
abscess of the right buttock with contracture of pelvic tro- 
chanteric muscles. He was sent to the Pitie on medicolegal 
grounds. 

September 22 there was found a slight laxity of the patella 
tendon, as well marked on the left side as on the right. The 
right side was more cyanotic, due to the inactivity of the limb. 
There was no edema. Tendon and skin reflexes were normal. 
The lack of power was diagnosticated as purely functional, 
and the report was rendered that the soldier could begin to 
walk as soon as he desired. The two knee-jerks were noted 
to be stronger and poly kinetic, and the right knee-jerk ap- 
peared a little stronger. 

The patient was chloroformed, October 25, 1915. Almost 
immediately, the knee-jerks, Achilles jerks, plantar, and 
cremasteric reflexes disappeared. During the first period of 
anesthesia, there was no accentuation of the reflexes, but at 
the beginning of recovery the anticipated reappearance of 
the right knee-jerk was observed. This knee-jerk was already 
sharply defined at a moment when the left knee-jerk was still 
abolished. In a later phase of recovery, the right knee-jerk 
was very markedly exaggerated and a patellar clonus was 
demonstrable on the right side. Even percussion of the left 
patellar tendon brought about a contraction of the right 
adductors. There was a true clonic and tonic spasm of these 
muscles. On the other hand, percussion of the right patellar 
tendon was able to provoke no contraction of either right or 
left adductors. Nor was there at any time any ankle clonus. 



SHELL-SHOCK: NATURE AND CAUSES 385 



Hysterical lameness (bullet wound of calf) cured, 
but the associated " reflex" disorder (in the sense of 
Babinski and Froment) NOT cured. 



Case 277. (Vincent, April, 1916.) 

A corporal was wounded by a bullet in the calf, September 
8, 1914. At the end of July, 191 5, his lameness continued and 
he disliked to lean on his left leg which bent under him. There 
was a slight atrophy of the left calf. The lower leg could not 
be extended upon the thigh if the foot was in dorsal flexion, 
and the dorsal flexion of the foot was itself limited. There 
were no reflex, vasomotor or electrical disorders. The man 
was given the usual treatment by Vincent and soon learned 
to carry his body on either foot, and, being well disposed, 
speedily abandoned his lameness, acquiring such skill in 
movements that he became monitor over the other soldiers, 
watching over them in his capacity as corporal. 

For about a year he thus served as monitor, and when fully 
Pressed did not seem abnormal or look as if he were walking 
lame. However, after walking, say 6 kilometers, rapidly, he 
dragged his leg; nor was extension of the lower leg upon the 
thigh absolutely complete in habitual walking, though he was 
able to extend perfectly if requested. Dorsal flexion of the 
foot was also still somewhat limited, and the measurements 
of the two lower extremities at both calf and thigh showed a 
persistent slight atrophy on the left side. He was then sent 
into the auxiliary service and did good work as draughtsman. 
In the winter the left foot got cold rather easily. 

This case is instanced by Vincent to support the contentions 
of Babinski and Froment that the truly " physiopathic " or 
"reflex " disorders do not completely clear up in the recovery 
from the associated hysterical disorders. That limb, which is 
the seat of physiopathic disorder, is not in a state of meio- 
pragia. 



386 shell-shock: nature and causes 



Foot trauma : Pains and dysbasia, hysterical ; slight 
atrophy of calf, physiopathic. Differential dis- 
appearance of hysterical symptoms ; increase of phy- 
siopathic symptoms. 



Case 278. (Vincent, April, 191 7.) 

Clovis Vincent examined a man who had been wounded in 
the foot but without injury to the bones. He was first 
examined in July, 191 5, when he complained of foot pains and 
was walking with crutches. The left calf was smaller than 
the right (4 cm.). The tendon reflexes were normal. There 
was no abnormality of electrical reaction. There was no 
proportionality between the trouble with walking and the 
organic status. A large part of the trouble appeared to be 
hysterical. In fact, upon treatment, the man was soon able 
to abandon the crutches and to walk, though lamely. He 
was put into the auxiliary military service. 

However, the pains grew more marked and the lameness 
increased. Incapable of working, the patient was sent to 
the neurological center at Montpellier, whence he came to the 
neurological center at Tours in September, 1916. He had 
never been confined to bed, and had never ceased his daily 
walking, aided by a cane. The walking disorder was very 
pronounced. The patient said he was still suffering much. 
The difference between the two calves was now 8 cm. and the 
thigh was atrophied, though the atrophy had been absent in 
July, 191 5. There was hyperexcitability of leg muscles. 
The right foot was colder than the left. The hysterical phe- 
nomena, so pronounced in July, 191 5, were now absent, yet 
the reflex phenomena were sufficient to invalid the man. 



SHELL-SHOCK: NATURE AND CAUSES 38; 



Shell-shock paraplegia may AFTER TWENTY 
MONTHS develop vasomotor and secretory dis- 
orders : The whole to vanish on treatment. 



Case 279. (Roussy, April, 1917.) 

A foot chasseur, 22, a farmer in civil life, sustained shell- 
shock d distance, June 2, 1915. He had no wound, but lost 
consciousness. He was evacuated for "contusion of back" 
to a hospital June 4 to 12; for " contusion of back and com- 
motio cerebri 11 to Portarlier, to July 21; for "internal con- 
tusions and commotio cerebri " to Besancon, where he was 
in three hospitals up to May 31, 191 6, and the diagnosis 
"hysteria, old commotio cerebri and trepidant astasia- 
abasia " was rendered and psychotherapy tried. The man 
was then evacuated to Saint Ferreol and the diagnosis "hys- 
terical paraplegia " rendered. He finally reached Veil- 
Picard in February, 191 7, still victim of paraplegia. 

Up to this point there had been no signs suggestive of 
organic lesion of the spinal cord or any hysteroorganic inti- 
mation whatever. But in February, 191 7, besides the motor 
disorder there was a hypothermia of several degrees, with 
cyanosis and hyperidrosis of both feet, with a marked dim- 
inution (and absence on one side) of the plantar cutaneous 
reflexes. The man was also victim of ' ' hysterical pregnancy. ' ' 
The cyanosis, hypothermia and hyperidrosis lasted six weeks. 

March 23 the man was given treatment and for the first 
time in 21 months was able to stand and walk. The foot 
now turned from blue to red, and instead of cold became 
warm, even hot. In about a week the hyperthermia di- 
minished, and, with the other troubles, disappeared. There 
remained only a slight swelling of the foot and ankle joints, 
due to the painful exercises given the patient. 

It would seem, then, that a hysterical paraplegia of long 
duration may finally associate itself with marked vasomotor 
and secretory disorders and that these may be altered with 
extreme rapidity on the very day in which the hysterical 
phenomena are removed, and quite disappear in a fortnight. 



388 SHELL-SHOCK: NATURE AND CAUSES 



TETANUS clinically cured : Phenomena in part re- 
produced UNDER CHLOROFORM ANESTHE- 
SIA five weeks afterward. 



Case 280. (Monier-Vinard, July, 1917.) 

An infantryman, wounded at Notre Dame de Lorette, May 
9, 1915, by a shell fragment in the right popliteal space, was 
given a preventive injection of 5 c.c. of antitetanic serum, 
evacuated to a hospital, May 12, and developed signs of 
tetanus August 1, with trismus and pains and spasms in the 
right leg. 

The disease < progressed with dysphagia, stiffness and par- 
oxysmal hypertonia of the legs, especially of the right leg, 
fixed orthotonus of the trunk, neck hyperext ended, arms stiff 
but able to move. Antitetanic serum was given daily. At 
the end of eight days there was a marked improvement and 
the whole course ran to approximate recovery in 25 days from 
the onset of tetanic symptoms, at which time the man was 
able to get up and walk on a crutch. The external popliteal 
nerve had been sectioned, and the foot was in a marked 
equinovarus. 

Chloroform was administered for the purpose of straighten- 
ing the foot, September 2, that is, about five weeks after the 
apparent end of the tetanus. The first stage of the anesthesia 
lasted about two minutes, but at this point the trunk and leg 
muscles passed into a state of diffuse contracture. In fact, 
a tetanic syndrome took place in the midst of the anesthesia. 
At a time when the corneal reflex was completely abolished, 
it was still impossible, with the exertion of the greatest 
strength, to flex the segments of the lower extremities. 
Moreover, the trunk was stiffly extended and the jaws were in 
trismus. Tonic and clonic contractions were produced by the 
efforts made to straighten the foot, and these contractions 
passed from the right side to the left. The chloroform was 
now increased and a transient resolution of the muscles was 
obtained, lasting hardly more than a half minute. As all 
efforts to reduce the pedal deformity failed, anesthesia was 



shell-shock: nature and causes 389 

stopped. The contractures and paroxysms lasted a few- 
minutes. The knee-jerks were extremely exaggerated and 
there was a bilateral ankle clonus. After a brief phase of 
excitement, the patient emerged from anesthesia, began to 
talk with his comrades, and ate his usual meal without in- 
convenience. The chloroform anesthesia had lasted twenty 
minutes, and 60 grams had been administered. 

It was now determined to section the tendo Achilles and 
the tibialis posticus. September 8 the man was chloro- 
formed again and the same phenomena were exactly repro- 
duced. Sixty grams of chloroform was again administered. 
The tendon resections permitted placing the foot in the proper 
attitude. Next day the patient was examined neurologi- 
cally. The skin reflexes were found normal. The Achilles 
and knee-jerks were somewhat exaggerated, but equal on the 
two sides. There was no ankle clonus. Sensations proved 
normal. There was a mechanical hyperexcitability of the 
muscles of the anterior aspect of the thighs and of the calf. 

In another case chloroformed 17 months after recovery 
from tetanus no such phenomena appeared. It would 
seem that the impregnation with tetanic virus or toxin must 
last in the nervous system a good deal longer than the appar- 
ent disease clinically lasts, but that this belated and con- 
cealed intoxication eventually passes. 

The phenomena are perhaps analogous to those of Babin- 
ski and Froment's so-called post-traumatic physiopathic or 
reflex phenomena. It was following the special work of 
Babinski and Froment upon the use of chloroform anes- 
thesia in detecting physiopathic conditions that Monier- 
Vinard made his observations in cases of tetanus. 



390 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock from falling of shell at a distance: 
Hysterical hemiplegia, terminating in brachial mono- 
plegia. Case to show that the reflex or physiopathic 
disorders of Babinski and Froment may occur with- 
out mechanical injury in the region involved. 



Case 281. (Ferrand, June, 191 7.) 

A soldier of the class of 191 7 who never went to the front, 
while in training at Belfort, felt violent emotion on the occa- 
sion of the falling of a big shell in the town of Belfort. The 
explosion was a good distance from him. He lost conscious- 
ness a few moments, February 23, 1917, and almost at once 
found himself unable to move his left side. He was hemi- 
plegic three months, but his leg shortly regained power. 
December 23 he entered a neurological center with his arm 
flaccid and a paralysis affecting the shoulder also. There 
was an almost complete anesthesia of the arm terminating in 
segmentary fashion about the shoulder, and the whole of 
the left side was slightly hypesthetic, although there was no 
disorder of motion except in the arm. The tendon reflexes 
of the left arm were exaggerated, and there was even con- 
tracture upon percussion of the muscles themselves. Per- 
cussion of the thenar and hypothenar eminences produced 
movements of the hand. There were several vasomotor 
disorders. Percussion led to large vasomotor plaques, and 
rubbing of the skin produced a reddening which passed away 
slowly. The hand was red and cold. Slight electrical hyper- 
excitability of flexors with feeble galvanic current ; excitation 
of the extensors not associated with any contractions of the 
antagonist muscles. Threshold lower for flexors on the 
affected side in the forearm. Half centimeter atrophy of the 
biceps. The forearm and hand were possibly slightly in- 
creased in volume from a blue edema of the dorsal surfaces. 
The man was very timid, complained little, and accepted all 
treatment, which, however, was not very effective. This is 
presented by Ferrand as a case with physiopathic disorder 
in the sense 'of Babinski and Froment, though it does not 
present any sign of organic lesion whatever. 



shell-shock: nature and causes 391 



Shell fire: Delayed shell-shock symptoms, sub- 
lethal, appearing in England. 



Case 282. (McWalter, April, 1916.) 

A soldier was picked up insensible in the public street and 
brought to hospital by ambulance, unconscious, breathing 
stertorously, pupils dilated, lips parched, unresponsive to 
stimuli, but without signs of injury or alcoholism. 

The pulse grew slower, the respirations more sighing, the 
heart-beat more diffused and labored; but towards evening, 
about eight hours after admission, he began to move the 
eyelids and lips, and muttered a response to the request for 
his name. After ten more hours, respiration grew better, 
and Croton oil led to a movement of the bowels. Natural 
sleep intervened, and 18 hours after the onset of unconscious- 
ness, the man woke up, and in the course of a few days 
became fairly well though still dazed and confused. 

This soldier had never received any definite injury in his 
war service, but McWalter attributes his break-down to the 
effects of the constant shocks from the bursting of shells, and 
the scattering of shrapnel. 

McWalter generalizes that a soldier, in the course of some 
civil occupation after the war, might develop symptoms, even 
fatal symptoms, and still the death in the case would be a 
direct consequence of the war. 



392 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock symptoms, some initial, with recovery — 
others late and gradual, with deterioration. 



Case 283. (Smyly, April, 1917.) 

A soldier became blind, deaf and dumb, as well as paralyzed, 
as a result of shell explosion. When he arrived at the hospi- 
tal, he was able to see but had visual hallucinations. In a 
few days he recovered his hearing. There was a fine tremor 
of the hands, controllable by suggestion. There was an 
almost complete amnesia, but the patient remained able to 
read and write. 

The pain persisted several months. The patient was 
physically well and seemed perfectly intelligent despite his 
aphasia and amnesia. One night, he sprang out of bed, shout- 
ing, "The guns are coming over us!" and from that time 
forward was able to speak. Amnesia, however, supervened 
for the months in the Dublin Hospital, and the patient 
believed that he was still in France. He also became unable 
to read or write, and was unable to recognize any letters 
except those he had been taught to speak during his period 
of dumbness. Stil later he got a flaccid paralysis of the legs. 
From seeming perfectly intelligent, he began to seem markedly 
deteriorated. Hypnosis with waking suggestions had no 
power upon him. After a time, intelligence reappeared, but 
there had not been any recovery of locomotion at the time 
of report. 



shell-shock: nature and causes 393/ 



Wounds, gas, burial : Collapse on home leave. 



Case 284. (E. Smith, June, 1916.) 

A non-commissioned officer went through the first eleven 
months of the war in France and Flanders and was subjected 
to every kind of strain therein. He was wounded twice, 
gassed twice, and buried under a house, in each instance being 
treated in the field ambulance and returning to the trenches. 
Some time thereafter he was granted five days' leave. 

On reaching home, while waiting for a train, the officer 
suddenly collapsed and became unconscious. For months 
thereafter, he was the subject of a severe neurasthenia; "the 
whole of his trouble seemed to be due to the dread, lest on his 
return to the front, the added responsibilities which would 
fall upon his shoulders might be too much for him." He 
thought his intelligence had been numbed by his experience. 
He thought his memory was unreliable, and that he could 
understand neither complex orders nor even the newspapers. 

As to the reason for his maintenance of composure at the 
front, this may be laid to the excitement, the officer's sense 
of responsibility, and the example he felt he should set his 
men. This kind of case " demands a great deal of patient 
and sympathetic attention before the real cause is elicited, 
and then months of daily reeducation to build up anew the 
man's confidence in himself." 



394 SHELL-SHOCK: NATURE AND CAUSES 



Bullet wound of neck : Late sympathetic nerve effect. 



Case 285. (Tubby, January, 1915.) 

A Belgian was wounded, October 21, 1914, at Dixmude. 
The bullet wound was just below the right mastoid process. 
He was admitted to the London General Hospital, October 
29. He said that the bullet had passed into the tonsil, 
lodging there, but that on the third day, while vomiting, he 
brought up the tonsil with the bullet in it. There was in 
fact a large ragged wound at the site of the right tonsil. He 
could swallow fluids only, but articulated clearly. There 
was a question of injury to the following nerves: facial, 
glossopharyngeal, vagus, hypoglossal, spinal accessory, and 
sympathetic. None of these nerves, however, appeared 
actually to have been injured. The difficulty in swallowing 
was due probably to the faucial wound, and it is hard to see 
how the pharynx could have been involved on account of 
the perfect articulation. November 3 the right sympathetic 
nerve was slightly affected ; the right pupil was smaller than 
the left although it reacted to light. November 12 the 
patient left the hospital and nothing further is known of his 
history. Thus there was a late effect upon the sympathetic 
nerve thirteen days after the wound. 

Re peripheral nerve disorders, see remarks under Case 
252 (Tubby). 



SHELL-SHOCK: NATURE AND CAUSES 395 



Fall from horse under shell fire : Crural monoplegia, 
hysterical. Reminiscence? Autosuggestion? 



Case 286. (Forsyth, December, 191 5.) 

A patient of Forsyth had been exercising a high-spirited, 
horse. Artillery fire close by made the horse leap sidewise, 
and the rider fell, his back striking the ground. He seemed 
to be curiously shaken out of proportion to the gravity of 
the fall. In a day or so, he lost the use of one leg. 

He recalled a rather similar incident: He had taken a hand 
in a local uprising in a distant quarter of the world. While 
he was escaping up a mountain track, a rifle-shot from the 
enemy brought down his horse, which rolled over and threw 
him violently against a boulder, where the small of the back 
met the force of the impact. He felt intense pain and lost 
consciousness. Upon recovery he found he was paralyzed. 
At the end of several days, in a hiding-place in the rocks, he 
found himself still unable to move his legs. The friend who 
had carried him to the hiding-place refused to leave him. 
He thought of suicide, but then discovered that he could 
move: at first, the big toes, then the ankles, then the knees, 
and finally the hips. He was finally able to get into the saddle. 

Moreover, years before, he had heard that a man who 
broke his back was paralyzed in the legs. 

Re autosuggestion, Babinski remarks that suggestion may 
work in hystero-organic cases not precisely as in hysterical 
cases. Autosuggestion may here replace or accompany the 
ordinary heterosuggestion. Some temporary disturbance - — 
a slight pain, a trivial injury, or a mere bruise — may start up 
a complex process of autosuggestion in which it may be diffi- 
cult to unravel the part played by the patient's own reflexes, 
his previous experience and beliefs (in this case, the remi- 
niscences of a similar accident), the solicitude of his friends, 
and the medical examination itself. Babinski believes that 
hysterical paraplegia or monoplegia never appears automati- 
cally under the influence of emotion ; never appears after the 
manner of sweating, diarrhea, or blushing. 



396 SHELL-SHOCK: NATURE AND CAUSES 



Shell explosion; struck in cave-in: Symptoms in 
right leg (antebellum experience). 



Case 287 (Myers, March, 1916.) 

A private, 26 years old, had 11 months' service and one 
month's service in France. He arrived at a base hospital 
the day after his shock. Concussion had caused the dug-out 
in which he was standing to collapse. A beam struck him 
on the left side of the face, and pinned him to the ground on 
his right side. A piece of iron fell on the left side of his back, 
and his right leg was pinned by a cross beam on the back of 
his thigh. He was dazed by the shock; was released and 
was able to walk, but complained of a pain in the right groin 
and a giving- way of the right knee. The medical officer 
arrived about an hour later. A numbness, or state of no 
feeling, in the right thigh appeared, and increased to the 
point of total analgesia to the level of the upper margin of the 
patella save for a narrow strip in the mid-line on the posterior 
aspect of the leg. The only area of complete anesthesia and 
algesia was on the outside of the lower half of the leg. 

According to the patient, it seems that about three years 
before, he had been buried four feet deep in a brick yard, 
beneath a heap of clay. He had felt it most in the right leg, 
but the thigh had been merely stiff and sore, and not numb. 
The patient admitted that the present accident immediately 
reminded him of his previous experience. There were no 
tremors or sensory disorders in the face, arms, chest, back, 
or abdomen. There was diminished sensibility to cotton 
wool of the left buttock (across which a plank had fallen), 
and there was a degree of hypalgesia of the buttock. The 
right thigh showed a degree of thermanalgesia and slight loss 
of vibratory sense. The corneal and conjunctival reflexes 
were diminished, and the knee-jerk was unobtainable on the 
right side. Three days later, there was a marked improve- 
ment with almost complete return to normal, whereupon the 
patient was sent to a convalescent camp. 



SHELL-SHOCK: NATURE AND CAUSES 2>97 



Emotional subject, ALWAYS WEAK IN LEGS; 
shell explosion; wound of back: PARAPARESIS. 



Case 288. (Dejerine, February, 1915.) 

A Lieutenant, 25, was wounded at Arras about 10 a.m. 
October 20, 1914, just as he was leaning on another officer's 
shoulder looking at a card in a chateau room. A shell burst 
in the court yard. A fragment came in the window, struck 
him in the back and pushed him forward, whereupon he felt 
pain in the back and a severe dyspnea, due to the gas from 
the shell. He lost consciousness several times and the 
dyspnea lasted for about two hours. When he was picked 
up he could not walk. 

He was carried on a stretcher to the ambulance at Avin- 
le-Compte. During the fortnight there, he was also several 
times dyspneic. Strength left his legs and he could only get 
about on crutches. There was now a suppurating wound in 
the interscapular region where he had been struck by the 
shell fragment. Evacuated to Paris, he was operated upon 
on account of a tremendous abscess in the back, and the 
shell fragment and some bits of cloth were removed. The 
wound healed; but vague pains in the left thorax remained, 
especially when the man walked. 

On examination, July 28, 191 5, he would in the stand- 
ing position hold his legs together with the feet resting on 
their external borders, especially on the left side. The toes 
were in plantar flexion, and the soles were arched upward 
more on the left side than on the right. In walking, the legs 
were always held in extension, the feet twisting outward. 
If an attempt was made to walk quickly, the man walked 
more and more upon the external borders of his feet, in such 
wise that the plantar surface and the heel turned up and 
became visible from above. He would get tired after five 
minutes' walking even if he spread his legs out for a broader 
base of action. He could lift his legs only about 10 cm. from 
the bed, but could flex and slowly extend his lower leg on the 
thigh. He could not adduct or abduct the feet. Move- 




398 SHELL-SHOCK: NATURE AND CAUSES 

ments of extension and flexion of leg on thigh were jerky and 
abruptly terminated, as also movements of thigh on hip. 
The patient could not sit, and when leaning forward he could 
not straighten up against resistance. The reflexes were nor- 
mal. There was no sensory disorder. The electric reactions 
were normal. Pupils normal. There was slight hyperten- 
sion of the spinal fluid and a slight excess of albumin. There 
were no lymphocytes. 

In accordance with Dejerine's idea that these neuropaths 
always have antecedents looking in the same direction, it 
was found that he had always been an emotional person, 
easily affected, sympathetic with other people's troubles, 
given to weeping. As Lieutenant, he had not had the cour- 
age to harangue his soldiers. He had often during his life 
felt his legs weaken during times of emotion and had some- 
times been unable to walk, though nothing of the sort had 
happened during the campaign. He was sure he could get 
well, and wanted two months' leave in order to get back to 
the front. There were no hereditary features in the case. 
A physician had told him that he had had meningitis. This 
possibly followed whooping cough. He had had orchitis 
after mumps at 16. He had not had children, nor had there 
been miscarriages since marriage at 21. 



SHELL-SHOCK: NATURE AND CAUSES 399 



Wound near heart ; delayed medical care ; fear of 
having been shot through heart: Paraparesis 
(antebellum always " hit in the legs. ") 



Case 289. (Dejerine, February, 1915.) 

An infantryman, 20, was sent as a Colonel's bicyclist 
about 1 p.m. September 30, 1914, with a message to one of 
the battalions. He was exposed on the way to shell and 
rifle fire, and was wounded by a bullet which entered 8 cm. 
below and internal to the left mammillary line and came out 
in the region of the left hypochondrium. He crawled to 
some village houses 20 or 25 meters away. Another cyclist 
came to transfer the order, but could not help him. A friend 
came to his aid but was struck by a bullet 10 meters off and 
remained on the ground for an hour while the young cyclist 
lay behind a tree on the roadside. At 3 o'clock it was 
possible to take him to a house around which shells were 
raining. Shortly afterward the house caught fire. The man 
was evacuated 6 kilometers to an ambulance in the night, 
and that night six of his wounded comrades died in the same 
room. The man had lost much blood and began to think 
that his heart had been hit. He choked, had violent palpita- 
tions, and intense thirst. By automobile next day he was 
taken to the railway station at Maison and was there for a 
day practically without food. 

That evening, 36 hours after the wound, he was evacuated 
to Juivisez and stayed there one night in the temporary hos- 
pital. The hemorrhage had now practically ceased. When 
he arrived next morning at Vincennes he could hardly move, 
was unable to walk, had violent palpitation, precordial pain, 
and two nervous seizures, with outcries and weeping. Sev- 
eral days later he could not walk at all or raise himself in bed. 
He was operated on May 29 ; he afterward felt the same leg 
weakness and was still unable to walk. Early in December, 
when observed by Dejerine, he was able to stand on crutches 
with legs flexed, toes on the ground, and heels up. In walk- 
ing he would scrape the ground with the dorsum of the foot. 



400 SHELL-SHOCK: NATURE AND CAUSES 

The wound was now healed. Suppuration had been intense 
and the scars were extensive. Lying down, the man could 
move, though slowly, his lower extremities in every way, 
nor was there any diminution in the strength of his flexors 
and extensors. The patient in making movements against 
resistance would let go quickly and jerkily. The plantar 
reflexes were flexor but weak. There was no other reflex 
disorder, no evidence of sensory disorder, nor any sign of 
neuritis or arthritis. Lumbar puncture gave a normal fluid 
without tension. 

There were no hereditary features in the case. The man 
had been in childhood nervous and irascible, rolling on the 
ground, crying and weeping when crossed. He had had 
three attacks of appendicitis — one at 15 years and two at 
19 years. After each attack he had felt weakness in the legs. 
He remembered, too, that after his nervous crises on being 
crossed, he had always felt this same weakness. 

According to Dejerine, these paraplegic neuropaths, like 
functional gastropaths, cardiopaths, and victims of urinary 
disorder, have had earlier spells of the same kind, though 
milder than the attack which brings them to medical notice. 



shell-shock: nature and causes 401 



Wounds : Tic on attempts to walk ; tremors. Re- 
covery except for frontalis tic (ANTEBELLUM 
HABIT emphasized). 



Case 290. (Westphal and Hubner, April, 191 5.) 

A substitute officer (mother nervous; always slightly ex- 
citable, easily fatiguable; had had a habit of wrinkling his 
forehead) sustained wounds September 8, 19 14, in the foot 
and thigh. The wounds healed well, but in the hospital 
he slept badly and had battle dreams. When he essayed to 
walk, he had contractions of face muscles. There was a 
lively tic involving both face and neck muscles, with the 
head pulled to one side and backward. This grimacing 
was but slightly influencible by the will. There was a 
marked tremor of the arms. Gait was trippelnd. There 
were tremors of the whole body. There was also a slight 
hemi-hyperesthesia. The tendon reflexes were very lively; 
vasomotor disorders (feelings of cold and perspiration). 

Seven months later the phenomena had all disappeared 
except for slight tic-like frontalis contractions. 

Re heredity and soil, Mairet investigated 22 cases of Shell- 
shock, and found a hereditary taint in eight, and an ac- 
quired predisposition in nine. He found hereditary taint 
definitely absent in seven, and acquired soil definitely absent 
in six; whereas the rest of the cases were doubtful. He found 
both the taint and the soil in five cases ; two cases with he- 
reditary taint alone; no case acquired, non-hereditary. 

In eight cases with head trauma, Mairet found three with 
hereditary taint, four without such; against one with an 
acquired predisposition, four without such, others doubtful. 

Re cases of somatic trauma (not affecting the head) , among 
five examined, there were none with hereditary taint, three 
definitely without taint, and five definitely without predis- 
position. According to Babinski, neither hereditary taint 
nor prepared terrain needs be found in hysterics. 

A predisposition is not thought important by Oppenheim, 
especially as so many normal persons are predisposed. 



402 SHELL-SHOCK: NATURE AND CAUSES 



War strain (fatigue, emotion) : Hysterical hemi- 
plegia. Precisely similar hemiplegia ANTEBEL- 
LUM. 



Case 291. (Roussy and Lhermitte, 1917.) 

A sergeant in a regiment of cuirassiers was observed at 
Villejuif, January 25, 1915. He had lost power on the left 
side as a result of fatigue and emotion, November, 1914. He 
had a complete paralysis of the left arm and a paresis of the 
left leg. There was an anesthesia of hysterical type in the 
left arm, and also of the left leg as far as the middle of the 
thigh. He dragged his leg in walking {demarche en draguant : 
the toe is dragged along the ground, the trunk is bent for- 
ward, and at every step plunges somewhat toward the par- 
alyzed side. The patient is able to walk, however, by means 
of a cane or crutches. This walk is characteristic of hys- 
terical hemiplegia. According to Roussy and Lhermitte, 
the number of cases of hysterical hemiplegia (better, hemi- 
paresis) is not large). The plantar reflexes on both sides 
were those of flexion. Upon treatment (not specified), at 
the end of six months he went back to service in the cavalry. 

The point of note in this case is that this patient had had a 
precisely similar phenomenon on the same side, which lasted 
a month, at the age of sixteen years and a half. It is note- 
worthy that in this case there was no traumatism and only 
the factors of fatigue and emotion to serve as an occasion for 
the hemiplegia. In fact, hysterical hemiplegia is said very 
rarely to follow physical trauma to an extremity. There are, 
however, some cases in which hemiparesis follows a slight 
head wound, particularly if over the region controlling the 
paralyzed limbs. 

During the six-months' course of successful treatment, no 
atrophy of limbs appeared, and there was never any in- 
equality of the reflexes. 



shell-shock: nature and causes 403 



A good soldier (son of a tabetic sometimes hemi- 
plegia), at 17 victim of hysterical hemiplegia, has 
AT 24 A RECURRENCE after two months' field 
service. " Functional excommunication" of left 
arm and leg. 



Case 292. (Dupres and Rist, November, 1914.) 

A cuirassier, 24, one month in the field, began to feel in 
September, 1914, crawling sensations in left arm and leg; 
then fingers, later hand and forearm, and finally upper arm 
began to work awkwardly and feel heavy, and there was a 
little of the same sort of thing in the leg. Hand and forearm 
were by the middle of October completely paralyzed, whereas 
the arm and shoulder were only paretic. Anesthesia at this 
time reached the elbow. The man had to be evacuated, 
after two months' active and skilful field service, in one 
instance (September 19) carrying out a clever and useful 
interception of hostile telephone messages. 

It seems that at the age of 17 also the man had had a left- 
sided hemiplegia, with sensory and motor symptoms, last- 
ing two months, cured by electricity applied with a small 
electrode in his village. The war situation was therefore 
actually a recurrence of the transient hysterical paraplegia. 

Moreover, the patient's father, 52, an old tabetic, had also 
several times shown a hemiplegia (however on the right 
side), a phenomenon which had strongly affected his son. 

It was curious that the slight residuals of movement which 
the cuirassier could perform could be made only while he was 
looking at the parts he was requested to move, and were 
impossible with eyes closed. The anesthesia was a total one 
when observed in November, 1914, coming to a sharp and 
circular termination at the shoulder and garter-wise above 
the knee — tuning fork insensibility in the same areas. The 
left patellar reflex was diminished when the eyes of the 
patient were leveled at the knee ; but a surprise test brought 
the knee-jerk out normally. The hand and fingers were a 
little darker in color, and the whole left arm a little colder 



404 SHELL-SHOCK: NATURE AND CAUSES 

than the right. There was also a slight amblyopia on the 
left side. 

This hysterical paraplegia proved rather resistant to 
psychotherapy. The patient seems to have systematically 
eliminated from consciousness and from action the entire 
function of the left arm and a good deal of the left leg. Du- 
pres and Rist speak of this as a kind of functional excom- 
munication of the parts. 

Re relapses, Wiltshire remarks that the frequency of re- 
lapses and the ways in which they are produced favor the 
conception that the original cause of Shell-shock must be 
psychic. Sir George Savage remarks that cases of Shell- 
shock should not return to the service under a period of six 
months on account of the frequency of relapse. Others have 
recently argued that such cases should not be sent back to 
the front at all. Harris notes that relapse may follow so 
apparently slight a factor as a vivid dream. Remarks con- 
cerning the true nature of relapses are made by Russell. 
Russell, for example, disapproves anesthetics in curing such 
a hysterical phenomenon as deaf mutism. This sort of treat- 
ment does not get at the real cause of the condition, so that 
the man is very liable to relapse with the same symptoms. 
Ballet and de Fursac note the many cases of relapse after 
treatment and after discharge. Sometimes the relapses were 
due to some unfortunate happening, but in other instances 
no external cause could be made out. Fear of having to 
return to the front is a factor in certain cases, so that the 
true answer to the relapse question may not come until 
after the war. 

Roussy and Boisseau insist upon the value of rapid cures 
(psychotherapy, electricity, cold shower, etc.), in diminishing 
the number of relapses. They maintain that these rapid cures 
abolish any chance for the man to brood over symptoms and 
thus to exaggerate and fixate them. These workers send 
their hospital return back to the regiments with a state- 
ment relative to diagnosis and the request that he be imme- 
diately returned to hospital if neurotic symptoms appear. 



shell-shock: nature and causes 405 



War strain; burial: Deafmutism. ANTEBEL- 
LUM speech difficulty. 



Case 293. (MacCurdy, July, 191 7.) 

A private 20 (always rather tenderhearted, disliking to see 
animals killed ; rather self-conscious ; a bit seclusive ; " rather 
more virtuous than his companions ,, ; shy with girls; sore 
throat a year or more before the war, with inability to sing 
or talk; always a lisper) enlisted in May, 191 6, spent five 
advantageous months in training and became increasingly 
sociable. However, on going to the front October, 191 6, he 
was frightened by the first shell fire and horrorstricken by 
the sight of wounds and death. He grew accustomed to the 
horrors and five months later was sent to Armentieres, where 
he had to fight for three days without sleep. He grew very 
tired and began to hope that he would receive wounds that 
might incapacitate him at least temporarily for service. 

He was suddenly buried by a shell, did not lose con- 
sciousness, but on being dug out was found to be deaf and 
dumb. On the way to the field dressing station he had a fear 
of shells. The deafmutism persisted unchanged for a month 
and then was completely and permanently cured in less than 
five minutes. He was made to face a mirror and observe 
the start he gave when hands were clapped behind him. He 
was assured that this start was an evidence of hearing; that 
his hearing was not lost, nor was his speech. He had no 
relapses during two months. 

According to MacCurdy, this case is a typical one of war 
neurosis of the type of a simple conversion hysteria. The 
man never suffered from anxiety or nightmares. 

Re burial cases, Grasset suggests that some of the patients 
probably think that they have actually died ; both sensation 
and motion have been lost, and it is naturally these that 
permit a man to believe that he is still alive. The classical 
case is recalled, of the almost absolutely anesthetic boy who, 
with eyes closed, at once fell asleep. Foucault's patient also 
said he actually thought he was dead after an explosion. 



406 SHELL-SHOCK: NATURE AND CAUSES 



War strain: Shell-shock and psychotic symptoms, 
with determination to parts injured ANTEBELLUM. 



Case 294. (Zanger, July, 1915.) 

Several years before the war, a cavalry officer had a severe 
concussion of the brain after a fall from his horse, but got no 
manifest symptoms therefrom except a mild transient deaf- 
ness. There must have been a vestibular nerve injury, how- 
ever, since there was a marked bilateral subexcitability of 
this apparatus later determined. 

In September, 1914, as the result of strains and privation 
in the field, he got vertigo and lachrymose spells, with some 
obsessions as though he would have to shoot himself in the 
foot or spring out at the enemy from the trench. 

In hospital at Jena, insomnia, anxiety, excessive perspira- 
tion and salivation, feelings of the death of various parts of 
the body, especially the forearms and hands, associated with 
hypesthesia of the parts, were determined. He had a feel- 
ing of vertigo on walking and was very sensitive to noise. 
He now developed a very intense and very variable degree of 
deafness on both sides, diagnosticated as nervous deafness. 
The caloric test demonstrated vestibular subexcitability 
above mentioned. We may suppose that in this already 
injured organism fresh disorder had set in on a psychogenic 
basis in the same region that had been injured years before. 



SHELL-SHOCK: NATURE AND CAUSES 407 



Mine explosion; emotion at death of comrades: 
Unconsciousness eight days with hallucinatory 
delirium; later, dizziness. History of previous 
trauma to head with unconsciousness and dizzi- 
ness. 



Case 295. (Lattes and Goria, March, 1917.) 

Sent at end of May to the front, an Italian soldier (Class 
1895, laundryman) was placed in an advanced post where he 
at once sustained great hardships. 

Father drunkard, mother healthy, sister nervous. Two 
brothers healthy, one brother died of tuberculosis. Patient 
had scrofula, scarlet fever, and bronchitis (tendency to rave 
intensely when in fever). At four, sustained a trauma on the 
head (skull depression), dizziness, loss of consciousness. 

June 7, a mine exploded in his vicinity, smashing several 
of his comrades. He did not himself fall to the ground, but 
was overwhelmed by a violent feeling of anguish. After a 
while, he lost consciousness. He woke up at Bologna, June 
15, as after a long sleep. During the interval he had been 
in a state of intense hallucinatory delirium day and night. 
Then his mind began gradually to clear, first with amnesia 
of the shock which had caused the trauma. Then he recalled 
this fact too. Dizziness, however, grew in intensity so that 
he fell to ground many times during the day. There were 
intermittent tremors in the limbs. 

Under observation, August 7, a sturdy, robust man. Some- 
what dull in demeanor. Senses intact. Cranial nerves 
negative. Tendon and skin reflexes lively, especially on the 
right. Memory intact, except for above-mentioned oniric 
delirium with restlessness and shouting at night, especially 
while falling asleep and waking up. Frequent intense dizzi- 
ness. 

The condition remained unchanged for a week. Patient 
transferred to another department, for acute catarrhal 
bronchitis with fever. 



408 SHELL-SHOCK: NATURE AND CAUSES 



Sniper stricken blind in shooting eye. 



Case 296. (Eder, March, 191 6.) 

An Australian, 19, was admitted to hospital for loss of 
sight in the right eye. There had been a right ptosis from 
childhood. January 7 nothing could be perceived but light. 

According to the patient, he was sniping through a loop- 
hole, November 15, when a bullet knocked a piece from the 
stock of his rifle. He continued at his post. There were five 
more shots, when another bullet struck the sand around the 
loop-hole. His right eye began to water. He shut the loop- 
hole and retired for an hour. His eye improved, he returned, 
opened the loop-hole, braced the rifle, and found he could not 
see the sights. He went to the physician. Vision grew 
rapidly worse, and in a few hours perception of light failed. 
He had been stricken blind in the shooting eye (the seat of a 
congenital deformity). 



Anticipation of warfare : Hysterical blindness. 



Case 297. (Forsyth, December, 191 5.) 

Anticipation of warfare may provoke a neurosis as in a 
case of Forsyth's. The man went blind training in England. 

It seems that four months before, while mounting sentry 
at night, marauding gypsies had felled him by a blow on the 
head from behind. He had returned to duty after a day or 
two and was now expecting to be moved to France. He 
said that while sitting with a friend, he began to feel giddy, 
turned a somersault, and fell unconscious ; and that on coming 
to, his mind was clear but everything was dark. For ten 
days he had been blind, although once he could see his parents, 
who visited him in hospital, almost clearly. His appearance 
under examination strongly recalled that of a blind man. He 
was induced to read some large print, then smaller print, and 
finally very small print. He then lapsed into blindness. 

He remembered that before enlisting, he had trained in a 
smithy, and heard that blacksmiths often went blind at the 
forge. 



SHELL-SHOCK: NATURE AND CAUSES 409 



Bareback riding: Spasmodic neurosis (similar 
ANTEBELLUM episode). 



Case 298. (Schuster, December, 1914.) 

A soldier, 32, had to do a long* stretch of riding bareback. 
As a result, he later suffered from tonic muscular spasms 
whenever he had to exert himself seriously, especially when- 
ever he had to move his legs and when sudden movements or 
sudden strong contacts were made. The attack appeared 
to be reflexly dependent on the pain. The case is regarded 
as one of the Wernicke Crampusneurosen, a disease some- 
what related with hysteria. 

A condition somewhat like the one developed in the war 
had occurred in this man at the age of seventeen after a 
drenching, but the attack was at that time much milder. He 
had, however, frequently had cramps in his legs. 



ANTEBELLUM spasm of hands, functional. 



Case 299. (Hewat, March, 19 17.) 

A boy, 19, had been passed as fit for laboring work at home. 
He had been a farm boy from 14. Once at 17 he had de- 
veloped whilst working amongst turnips in wet weather, 
pain in the hands, which got worse and was followed by pains 
in legs, arm, and neck, that kept him in bed a week, and from 
work ten days. Even on returning to work, his hands were 
swollen, though he was able to drive a horse. The fingers 
had been somewhat firmly flexed on the palms ever since this 
illness at 17. 

He was sent to Netley after three weeks of army work, as 
having a spasm of both hands. He was found to be mentally 
below par, nervous, apprehensive, stuttering in speech and not 
readily responsive, with defective vasomotor control, though 
of good average bodily development except for asymmetry 
of chest. 



410 SHELL-SHOCK: NATURE AND CAUSES 

Both hands were found firmly closed; tips of fingers ap- 
plied to palms; thumbs freely movable; forearms well de- 
veloped, especially the flexors. Counterforce was exerted 
upon passive extension of fingers. There was no sensory or 
reflex disorder, and while the patient was asleep, it was found 
that the first and second fingers of both hands could be fully 
extended. Yet there was a definite contracture of the 
palmar fascia which prevented full extension of the third and 
fourth fingers. He was awakened by this test and the fingers 
became firmly flexed at once. 

The man was treated by milk isolation behind screens, 
without permission to read, smoke, or talk. Twice a day he 
was encouraged to move the fingers and made to perform 
finger exercises. He became able to extend the fingers over 
half their normal excursion in three days, and was then able to 
abduct and adduct the fingers. He was allowed up in two 
weeks' time, with full diet and screens removed. The con- 
tracture of the palmar fascia was still in evidence, but the 
power of movement in the hands and fingers was so satisfac- 
tory that he could be sent back to duty in three weeks. The 
interpretation of Fergus Hewat is that the painful condition 
of the hands which set in in the illness at the age of 17, had 
caused an obsession which had developed into a functional 
spasm of the hands. 



shell-shock: nature and causes 411 



Quarrel: Hysterical HEMICHOREA, DOUBLY 
REMINISCENT, of a former hysterical chorea, 
itself related with an organic chorea of the patient's 
mother. 



Case 300. (Dupuoy, October, 1915.) 

A nineteen year old soldier, for some months a bit dis- 
tressed and irritable, had a dispute with an old man whose 
jug he unluckily happened to smash. The old man said 
something was going to happen to him for that. That day, 
in point of fact, he fell and sustained an injury with water 
on the right knee. He was upbraided by the captain and 
evacuated to the ambulance. The fellow thought the old 
man with the broken jug had interfered, dreamed of the old 
man's threats, and felt his hand on his shoulder. 

Next day hemichorea developed on the right side, a partial 
and rhythmic chorea with jerky, regular contractions, fifty 
to sixty per minute, affecting synchronously the muscles of the 
leg, arm, face and tongue. 

Dupuoy speaks of the reason for the hysterical " choice " 
of this disease, since his mother had had a probably organic 
hemichorea, also on the right side, with which she died at 
thirty years in a stroke. The boy was at that time thirteen 
years old and had had a rhythmic chorea six weeks, limited to 
the extensors of the hand on the forearm, treated in hospital. 

This new hemichorea was quickly and completely cured by 
psychotherapy. 



412 SHELL-SHOCK: NATURE AND CAUSES 



Hallucinations and delusions in a soldier, of ante- 
bellum origin. Treatment by explanation of causes. 



Case 301. (Rows, March, 1916.) 

A private, 31, — a case of Capt. W. Brown, — was ad- 
mitted to hospital suffering from hallucinations of hearing 
and delusions of supervision by his family and friends; he 
heard his relatives telling him what to do and what not to do. 
He thought they belonged to a secret police entrusted with 
the task of supervising his actions and seeing that he did not 
again transgress as he had done. An inquiry into his past 
revealed the following facts : 

He had been a bank clerk before the war and once because of 
a nervous breakdown as a result of drinking and smoking 
had been given a three months' vacation. On this occasion 
he went with a prostitute — his first and only offence in sex 
matters. He later thought the behavior of his family in- 
dicated that they knew of his misdeed. He heard the voices 
of members of his family, became rapidly worse and more 
depressed, and attempted suicide. 

He went to a private asylum. Later, he emigrated to 
Canada, but he was still pursued by the voices and he returned 
to England. He enlisted at the outbreak of the war and 
went to France. He was soon invalided and sent to Mag- 
hull. 

The cause of his condition, according to Rows, was his 
affair with the prostitute and his previous drinking. This 
was explained to him as the basis of his strong feeling of 
self-reproach. The hallucinations and idea of suicide had 
developed therefrom. Recovery "toa large extent." 



shell-shock: nature and causes 413 



A poor risk (hereditary and acquired) ; emotionality : 
Tremors and convulsive crises with lowering of 
pulse. 



Case 302. (Rogues de Fursac, July, 1915.) 

A man, 36 (boat painter to 30 and thereafter a wine seller; 
paternal grandmother insane, father alcoholic and suicide; 
gonorrhea, 20; two attacks of lead colic, 25 to 30; purulent 
pleurisy, 31; phlegmon of mouth, 34; also a chronic alco- 
holic), at the time of examination showed arteriosclerosis 
and slightly hypertrophic liver; unequal pupils, slightly con- 
tracted and sluggish to light. He complained of frequent 
headaches, possibly due to a combination of plumbism and 
alcoholism. He was not in any respect demented, and had 
an excellent memory. He had always been emotional, being 
unable to go to a funeral without many tears, or remain in a 
house where there was a corpse without threatening to faint. 
He was always overcome if he saw a fight going on ; and even 
in his wine shop he would escape when there was a fight and 
get a neighbor to bring the police. 

He was mobilized on the fifth day, sent first to a territorial 
regiment and then, in October, put into the reserve of an 
active regiment and sent to the front. He reached the first 
line trenches in the night, greatly affected by ruins he saw on 
the road. He slept poorly and had nightmares. At day- 
break he woke up to see a pile of corpses near by, and felt an 
indescribable terror on account of the corpses and the noise 
of bullets, machine guns, and shells. By superhuman efforts 
— according to the man — he mastered his emotions and 
took his turn at the observation post. Another sleepless 
night. Next day he got such tremors that his sergeant sent 
him to the hospital where he was at first thought to be suffer- 
ing from a fever. But his temperature was found normal, 
and he was sent back to the trenches. 

He passed another night without sleep, and next day he 
could not hold his gun for trembling. The Captain sent him 
back to be a kitchen man in the rear, and here he remained 



414 SHELL-SHOCK: NATURE AND CAUSES 

six weeks — restless, trembling, eating very little. He would 
have anxious spells. In the morning, as he was carrying 
coffee to the men in his company, on seeing a pile of corpses, 
he dropped his pot and ran back to the kitchen declaring that 
whoever wanted to carry coffee might, but he would not go 
back. He spilled a pot of soup on his left foot. The Captain 
had him evacuated, saying: "Go! when you come back, I 
hope the war will be over! " 

He was sent back to a hospital near Paris, where he was all 
right for a few days, happy as a prince. The burn got well, 
and as the time approached when he would probably have to 
go back to the front, the terror returned. He had visions of 
corpses, and imagined bullets whistling, machine guns pop- 
ping, and shells bursting. He wept, lost appetite, hid in 
corners, made three suicidal attempts by poisoning, — though 
the sincerity of these attempts was doubtful (zinc oxide oint- 
ment; rose laurel leaves; verdigris). Sent back to a depot 
before getting leave, he had crises of tremor with anxiety, 
and was then sent to Val-de-Grace on the mental service, and 
finally to Ville-Evrard. He unhesitatingly confessed his 
terror, becoming more and more anxious and tremulous, and 
almost losing his pulse while describing his experiences. He 
said he would commit suicide rather than return to the front. 
He stayed at the Hospital, working in the garden rather 
calmly, but when it was a question of leaving, even on con- 
valescence, his terror and anxiety returned. Every time he 
was examined there was an emotional explosion, with expres- 
sions of anguish, generalized tremors and crises of clonic con- 
vulsions with respiratory disturbance even of threatening 
suffocation, depression of pulse. It is this latter which is the 
most important element in the proof that such a case is not a 
case of simulation. 

Re war cases, Bennati remarks upon the great number 
that do not fall into known categories. There is, he thinks, 
an anaphylactic group in which the trauma acts as the 
secondary toxic agent; and there is another group in which 
exhaustion works after the manner suggested by Edinger: 
that is, by a physiological overwork of certain structures. 



SHELL-SHOCK: NATURE AND CAUSES 415 



Martial misfit, dwelling on horrors of war at home ; 
exposure ; shell fire : Mental exhaustion with de- 
pression, emotionality, tachycardia. 



Case 303. (Bennati, October, 1916.) 

An Italian corporal, in civil life a writer (mother very 
nervous; patient himself rickety, unmarried; relatives well 
off), was in front line trenches for some fifty days. He was 
repeatedly excused from service on account of fatigue, dis- 
tress, poor appetite, insomnia, depression and even confusion 
(aimless shots fired off in the night). It turned out that he 
had been in just this state of mind when he left home and 
family and that the very thought of war had seemed dread- 
ful to him. He did not at all enjoy leaves at night, as he 
stumbled and fell about in the darkness and had shells burst 
near by. He lived immersed in mud. He reacted unfavor- 
ably to antityphoid injection. 

The very day he went on winter furlough he greatly im- 
proved, but then suddenly relapsed into depression, emotion- 
ality, inattentiveness, sluggishness of mind, and exhaustion. 
The tendon reflexes were lively, the abdominal reflexes 
sluggish. There was tachycardia (120), the Mannkopf- 
Thomayer tests were positive at 76 and 80, oculocardiac 
reflexes 84 and vagotonic. Stellwag and v. Graefe symptoms. 



416 SHELL-SHOCK: NATURE AND CAUSES 






Hereditary instability. 



Case 304. (Wolfsohn, 191 8.) 

An English soldier, 23, had been ten months on active 
service in France, when he was buried by a shell December 
19, 19 1 5. He became unconscious and later suffered from 
nervousness and stuttering, depression, insomnia, frightful 
dreams, and tremor. Improvement was such, under treat- 
ment, that he was again returned to the front. A shell 
burst near him once more and again he grew dazed, trembled, 
had lapses of memory and fell into a state of general nervous- 
ness. He improved again in hospital. 

On returning to the front in a few days he saw a bomb 
burst some distance away. He began to stammer and to 
wander about aimlessly. Insomnia, tremor of legs, arms 
and head, fatiguability, feeling of lassitude, occipital and 
vertical headache, fear of aircraft and crowds, frightful 
dreams, absences and aimless wanderings appeared. There 
was one attack of deafmutism. Whenever the patient saw 
aircraft he ran. He was easily startled by noises. 

He was the son of an excitable, alcoholic father and of a 
nervous and bad tempered mother. A sister had had ner- 
vous prostration. The man himself had always been more 
or less moody and a nail-biter. According to Wolfsohn, 74 
per cent of the war neuroses have a family history of neurotic 
or psychotic stigmata, including insanity, epilepsy, alcohol- 
ism and nervousness ; 72 per cent show previous neuropathy. 

According to Wolfsohn, wounded soldiers do not show war 
neuroses except in rare instances. In the wounded soldiers 
studied by him no neuropathic or psychopathic stigmata 
occurred in the family history and previous neuropathic tend- 
encies in the patients themselves were found in about 10%. 

A soldier that is excessively fatigued or has been under 
undue mental anxiety, expecting to be blown to pieces, may 
go into psychoneurosis more easily than one without such 
emotional strain. 



shell-shock: nature and causes 



417 



Genealogical tree of a shoemaker. 



Case 305. (Wolfsohn, 1918.) 

An English private, shoemaker, 37, was partially buried in 
a shell explosion and came to, stupid, shaky, weak and fear- 
ful of the dark. Twice, in a dazed state, he attempted to 
murder companions and was afterwards amnestic. He had 
always been of a violent temper and his outbursts had been 
followed by petit mal. He had also always been afraid of 
the dark. One of his children had fits; three were hysteri- 
cal and had temper fits. The man's father was in an insane 
hospital. Sundry other facts are shown in the genealogical 
tree presented herewith. 



I violent temper 
prison, record 

■ insane 
.* prostitute 
•• imbecile 
-0 ITrtbecile 

-4 -men*, clef., 



[-•imbecile 
-A temper 

6 
□ 

-O 



1 violent outbursts 

I (died as result of one) 

2£ 



Pedigree 

note Vh.e stigmata all on. 
paternal side. 

frive chart reads from left 
to ri^hl.) 



crook. 

crook. 



K3 Status dance 

Jl crooK .rebel , 
rm prison record 



o 



-a 

Hi sexual manizc 



6 



insane criminal 
violent temper 
sexual maniac 

. ^S , 

I mental degea 

I emotional 
1 enuresis 

I violent 

■ outbursts 

■ violent, 

■ outbursts 



9 nervous 
9 nervous 
§ nervous 

* violent .. 

w outbursts 

restraint 

. nervous breaH 
'down follows 
hush* outlrorsts 



6 



PATIENT 
petit • mal 
violent temper 



fits of 
temper 



hysterical 
Hysterical 



nervous 
clever musician 
«* in studies 



— 6 



O 



418 SHELL-SHOCK: NATURE AND CAUSES 



Fall from horse in battle; fear of being crushed: 
Hysterical crises. Case offered as showing TRAU- 
MATIC HYSTERIA in a young physician WITHOUT 
HEREDITARY OR ACQUIRED PSYCHOPATHIC 
TENDENCY. 



Case 306. (Donath, 1915.) 

A physician of twenty went into the war as a volunteer 
Hussar. During an attack, he fell from his horse without 
losing consciousness, though he was at the time much afraid 
of being crushed. The attack ceased and he returned to 
the lines on horseback. 

Immediately there developed an emotional crisis, and 
thereafter he broke into weeping on the slightest occasion. 
He was afraid he was going to lose his reason; that some 
spiritual power was going to suppress his ego and madden 
him. He wept as he was going under narcosis to be operated 
upon for an intercurrent appendicitis. He became so sensi- 
tive to noise that he wanted to choke the offender. One 
day he bit himself on the arm in his excitement. Sensory 
tests could not be executed on account of his fear of the 
brush. Reflexes were normal. 

It took four hypnotic seances to get him in proper rapport 
with his physician for psychotherapy. 

This case is cited by Donath as one in which traumatic 
hysteria has been proved to exist in a man without any sign 
of neuropathic or psychopathic taint, either in his previous 
history or in his relatives. 



shell-shock: nature and causes 419 



A perfect soldier type. Mine explosion; burial; 
superficial wounds : War neurosis. 



Case 307. (MacCurdy, July, 191 7.) 

A lieutenant, 29, had been a regular soldier for eight years 
before the war and was made a non-commissioned officer 
almost at once after enlisting. He went out as a sergeant 
with the original expeditionary force and got through the 
retreat from Mons and the first battle of Ypres intact. He 
enjoyed the fighting hugely and even got indifferent to the 
burial work. The death of chums saddened him, but he 
carried on and soon forgot about the incidents. He might 
be regarded as a perfect soldier. 

In August, 191 5, there was a slight touch of rheumatism. 
Two or three months later the Germans exploded a mine 
immediately in front of the trench where he was. He went 
pale for the first time in his life, but kept his men "standing 
to." Thereafter he began to think for the first time about 
danger. Mining was hereabouts the chief form of attack, 
and he frequently heard Germans digging beneath a dug-out. 
He slept well in billets, but was too restless for sleep on 
active duty. 

He got more and more on edge during the next weeks. Six 
weeks after the mine explosion he was buried in a dug-out. 
Though he did not lose consciousness, he was dazed and had 
to lie down for two hours. Nervousness, chronic headache 
and insomnia, even in billets, followed. His imagination 
played upon the blowing out of dug-outs and the bowling 
over of men by shells. He had become company sergeant- 
major and the responsibility made him grow worse and worse. 
At times he tended to jump when the shells came, but was 
outwardly perfectly calm. He began to take morphia, 
though with little result. He had suicidal thoughts. 

After two months of these symptoms he was sent to 
England. He began to sleep fairly well and three months 
later applied for light duty; was greatly bored by the company 
accountant work given him; got a commission and was sent 



420 shell-shock: nature and causes 

back to the front nine months later, January, 191 7. He got 
on with the active fighting very well, sleeping four or five 
hours a night. In April he was sent to Arras. He had had 
a dream that he was going to be bowled over, buried and 
wounded in the neck. Sleep got poorer. In April he led his 
men in an advance and actually was bowled over, buried and 
hit in the neck as well as in the knee and the hand, though all 
the wounds were superficial. He was carried back, dazed, 
to hospital, where he grew fairly comfortable in ten days and 
even undertook a journey down to the base. 

He arrived in collapse, remained in camp at the base three 
weeks, getting steadily worse. Something, he could not tell 
what, was going to happen and kill him. He could not con- 
centrate, even to read. He thought of suicide. He slept 
practically not at all, waking from a doze with a start, feeling 
that something had hit him. He had dreams of being taken 
prisoner and on waking would in fancy start a fight to escape 
from imagined imprisonment back to the British lines. After 
two weeks in various hospitals he spent ten days in a hospital 
for nervous cases and grew better. Riding on trains he was 
terrorized in every tunnel lest he should be crushed. 

According to MacCurdy, an anxiety neurosis would have 
developed had not his superiors sent the lieutenant back to 
hospital after the final burial in April. As this perfect soldier 
said: " There is no man on earth who can stick this thing 
forever.'' 1 



SHELL-SHOCK: NATURE AND CAUSES 421 



Shell-shock ; thrown against a wall : Tremors — 
TREMOPHOBIA. 



Case 308. (Meige, February, 191 6.) 

Meige has studied shell-shock tremors, especially those 
occurring without external wound. 

A corporal was with his squad on the Nouvron Plateau, 
January 13, 1915, when he was thrown against the wall by a 
bursting shell, which killed or wounded several comrades 
but did not wound the corporal. Whether he lost conscious- 
ness is unknown, but he lay on the ground for some time, 
until he could be moved through a communication trench. 
After the explosion he began to tremble, and was still trem- 
bling on his trip back. Constantly trembling, he lived on at 
the front for a fortnight, but without eating; and, although 
he had been a good rifleman, he had lost all his former skill 
with a gun. 

There was a delay of a month before evacuation, but the 
trembling did not cease, and he was passed through various 
units, to the neurological center at Villers-Cotterets, where 
he remained for two months, — April 13 to June 15, 1915, — 
with a diagnois of hysterical chorea. He was examined by 
Guillain, who found, besides the generalized tremors, lively 
knee-jerks and Achilles jerks, an excessive emotionality, par- 
ticularly marked when the guns were going or bombs burst- 
ing. Lumbar puncture yielded a perfectly normal fluid. 

June 19 the corporal went to the Salpetriere under P. 
Marie. July 14 he was evacuated to the civil hospital of 
Arcueil, where he remained till September 24, when he was 
sent home to convalesce, from October 26 to December 15. 

He returned to the Salpetriere December 15, 1915. 
Throughout these various movements from hospital to hos- 
pital, his status was unchanged. At the time of report about 
a year after shell-shock, he was still constantly and uniformly 
trembling. All four limbs were affected, perhaps the right 
arm and the left leg more markedly. There was no tremor 



422 SHELL-SHOCK: NATURE AND CAUSES 






during sleep, but there was a tremor when the patient lay 
awake in dorsal decubitus just as when he was sitting or 
standing. The tremor was worse in the evening than in the 
morning, and the patient could get to sleep only very late. 
There was slight tremor of the head ; the eyelids and the tongue 
showed a few tremors, which were not synchronous with 
those of the limbs. Nystagmus was absent. To diminish 
the effect of the trembling, the patient held his forearms 
flexed and kept his elbows close to his body. If the trem- 
bling of the legs got intense, the patient would rise and walk 
a few steps. Any movement, such as carrying a spoon or a 
glass to the mouth, led to an exaggeration of the tremors; 
and there was at this time a suggestion of the intention 
tremor of multiple sclerosis. The tremor was increased when 
the eyes were closed. Any sudden noise or sharp command, 
or recalling to mind of trench service, would bring about 
extraordinary motor crises, in which there was an intense 
and generalized tremor, so the patient would lose his balance. 
Any attempt at eliciting reflexes would produce generalized 
violent tremor. Sensations were normal; tendency to hy- 
peridrosis; pulse in repose, 60, rising to 120 if one struck the 
table sharply. 

Meige remarks that a number of examples of tremors 
suggestive of Parkinson's disease were observed in the War 
of 1870. Might the explosion have caused properly situated 
lesions in the encephalon of such a nature as to produce a 
Parkinsonian tremor? The tremors were stationary, and 
if due to some lesion, the lesion remains now exactly what 
it was at the beginning. There was no digital tremor such 
as is characteristic of Parkinson's disease. Moreover, the 
intention tremor of such a patient, rather than Parkinson's 
disease, suggests multiple sclerosis, of which latter disease, 
however, there is no other sign. Nor does there seem any 
evidence that these tremors were of cerebellar, paretic, goi- 
trous, or of any definite toxic origin. On the whole, Meige 
regards it as a neuropathic manifestation resembling what is 
found in traumatic neurosis. He believes that there is not 
sufficient evidence that it is the consequence of any struc- 
tural change in the nervous system. 



SHELL-SHOCK: NATURE AND CAUSES 423 

Meige remarks that the analysis of any case of tremor 
must take the mental state into account. This patient, 
perfectly conscious of his tremors and their critical exacerba- 
tions, was much chagrined thereby. He suffered mentally 
from his impotence, especially when bystanders would in- 
tentionally bring about his paroxysms. He looked like one 
shuddering from fear, and it is actually probable that he was 
afraid of his own tremors and shuddering. He was, besides 
subject to tremor, also a victim of tremophobia, — a kind of 
phobia described some years since by Meige, somewhat re- 
sembling ereutophobia, or fear of blushing, described by 
Pitres and Regis. 



424 SHELL-SHOCK: NATURE AND CAUSES 



Four hours in a freezing bog: Hysterical glosso- 
labial hemispasm twelve hours after rescue. No 
sensory disorder of face or tongue; sensory dis- 
order of arm, but no motor disorder. 



Case 309. (Binswanger, July, 1915.) 

A man, 27 ', in good health, called on the second day of the 
mobilization, got into the line two weeks from mobilization, 
first in the West, and then, from mid-September, in the East. 
He was in the artillery and stood shell fire in a big battle 
very well. 

However, December 27, 1914, while engaged in transport 
service, on the way back with his horse, he fell into a bog 
and gradually sank to his neck. Attempts to get the man and 
his horse out failed. All that saved him from drowning was 
the freezing of the bog surface. After four hours he was 
freed by his comrades, apparently frozen stiff, but with con- 
sciousness completely preserved. On the next day, at about 
five o'clock, — twelve hours after his release from the frozen 
bog, — he had a seizure. It began with headache on the 
left side and loss of consciousness that lasted 24 hours. The 
right leg was paralyzed and very painful. He passed 
through various hospitals and finally arrived at the Jena 
Nerve Hospital, January 25, 1915. 

He was a tall, powerful man, with a slow regular pulse, 
accelerated heart sounds, lively dermatographia, increased 
muscular excitability, general increase of knee and Achilles 
reflexes (left greater than right), slight patellar and ankle 
clonus present on the left side, Babinski reaction absent, 
plantar reflex more lively on the left than on the right, but 
abdominal reflex more lively right than left. Head painful 
to percussion in the left temporal region. Touch and pain 
sense segmentally absent in both right extremities. Arm 
movements free; tremors absent. Active movements almost 
impossible in the right leg; on passive movement marked 
pain. Slight muscular tension about knee-, hip-, and ankle- 



SHELL-SHOCK: NATURE AND CAUSES 425 

joints. The patient got about with a cane, trailing the left 
leg. Romberg sign. 

The right angle of the mouth was withdrawn slightly 
upward and outward, and lagged a little in active move- 
ments. The protruded tongue deviated completely into the 
right angle of the mouth and there remained, but without 
tremor. The uvula deviated to the right, and the right 
palate was held higher than the left. Lively palatal reflex. 
Speech intact. The patient's chief complaint was attacks 
of coughing, which increased his headache to the point of in- 
tolerability. A harmless drug caused the coughing and 
headache to disappear. The patient was a quiet, willing 
man, who industriously went through his exercises, and on 
the Kaiser's birthday was already walking in the market- 
place. His tongue contractions gradually improved. His 
body- weight increased. 

In the course of two months the glossolabial and palatal 
contractions had largely disappeared. The walking move- 
ments of the right leg had improved, although there was still 
a distinct paresis, and a stiffness in the right knee and ankle 
joints. Climbing stairs was impossible on account of diffi- 
culty at the hip. March 30, 191 5, the sensory improvement 
was marked. There was a feeling as though the last three 
fingers of the hand were asleep; walking was improved; he 
could walk one or two hours a day. The walk was still 
slightly spastic-paretic, May 28, when he was discharged. 

It is remarkable that the hysterical attack had such a long 
incubation period in this case: twelve hours after his re- 
moval from the marsh. There were doubtless physical factors 
of refrigeration, on the one hand, and on the other, psychic 
factors of fear of sinking alive in the marsh, at the bottom of 
the phenomenon. The most marked feature, -of course, was 
the glossolabial hemispasm. In the presence of this hemi- 
spasm, it is remarkable that there should have been no 
anesthesia or analgesia of the face, cheek, or tongue; and 
moreover the paresis of the right mouth and tongue was far 
less marked than the contracture. It is also striking that 
the right upper extremity, although it had sensory disorder, 
failed to show motor disorder. 



426 SHELL-SHOCK: NATURE AND CAUSES 



Slight bruise by horse : Apparently invincible com- 
plaints of pain. Cure by single-handed capture of 
many Russians. 



Case 310. (Loewy, April, 1915.) 

An infantryman was standing below an embankment when 
a horse fell upon him, bruising him slightly on the left hip. 
This infantryman later continually complained of pains in 
the opposite hip though there had never been a contusion 
there, nor anything felt there. These complaints could not 
be influenced by exhortation, by diversion, or by drugs. If 
they were purposely ignored, the patient reacted complain- 
ingly and in a way to suggest delusions of persecution. 

Nevertheless, this querulous man soon proved an effective 
soldier in a storming attack in which the whole battalion 
distinguished itself, putting himself forward particularly. In 
fact, by himself he captured a whole group of Russians! 

Thereupon all the pains in the hip ceased, nor did they 
recur so long as he was under observation. Morose and 
complaining before, he now became cheerful. 



SHELL-SHOCK: NATURE AND CAUSES 427 



Kick in abdomen by horse: General spasticity; 
tremors ; eye symptoms (e.g. monocular diplopia) ; 
convulsions. Improvement. 



Case 311. (Oppenheim, July, 1915.) 

A cuirassier was kicked by a horse on left side of abdomen, 
November 24, and lost consciousness. A month later, in 
hospital, hardness and tenderness to pressure of abdominal 
wall, spastic muscles everywhere, pseudospastic tremor of 
legs, and complaints of double vision were noted. He also 
had attacks of convulsions, in which he became unconscious, 
twitchings appeared, but the tongue was not bitten. Urine 
was often involuntarily passed in these attacks, but he was 
not always continent outside attacks, as, for instance, in 
coughing. 

On admission to nerve hospital: Right-sided monocular 
diplopia; mild ptosis; ocular movements free. Rapid tremor 
on shaking hands. Stood with straddling legs affected by 
vibrating tremor. Knee-jerks considerably increased. In 
the dorsal position movements of the left leg were accom- 
panied by marked tremor. He even could not go to sleep 
easily on account of twitching of the left leg. 

His comrades observed that he had convulsions at night, 
and often spoke in his sleep. Inoculation against typhoid 
fever was made early in December. Later, permanent frise 
of temperature to 37.8. Several attacks, lasting about ten 
minutes, came under observation of the physician. 

In January, progressive improvement in the motor sphere 
and also psychically. The urinary disturbance likewise dis- 
appeared, but the spasms persisted. 



428 SHELL-SHOCK: NATURE AND CAUSES 



Windage from a shell; fear; fall, unconscious: 
Homonymous hemianopsia (organic? functional?) 
with blinking and vasomotor excitability. 



Case 312. (Steiner, October, 191 5.) 

A volunteer, 19 (never ill; no nervous disease in the 
family) after a period of training went into the field October 
3, 1 9 14. November 5 a shell struck near his trench, but 
failed to explode. Up to that time everything had been 
quiet. The soldier had been looking out of the loop-hole, 
surveying the landscape. He felt a great fear, felt a blow in 
the neck, and fell down unconscious. How long he was un- 
conscious is unknown. Sometime later he walked back with 
his comrades. 

About an hour later, this volunteer — who was a very 
intelligent young man, possessing some knowledge of biology, 
including the nature of visual fields — noticed a black spot 
in the field of vision, which came and went, but after a few 
hours remained continually without disappearing. Other- 
wise there was no complaint except a feeling of dizziness 
when stooping. 

Upon examination there could be found no disorder of the 
internal organs. Neurologically there was blinking, vaso- 
motor excitability, slight reddening of the face, and derma- 
tographia. An expert in ophthalmology confirmed the exis- 
tence of a homonymous defect in the fields of vision. This 
defect could not be influenced by suggestion or by any other 
treatment, nor did any other change whatever occur in the 
condition. 

Steiner inquires whether this hemianopsia is to be taken 
as organic or functional. The air-pressure of the shell hiss- 
ing past might have produced a concussion, or the falling un- 
conscious might have produced a commotio cerebri or a slight 
hemorrhage. The tic-like blinking and vasomotor excit- 
ability, however, suggest functionality. 



shell-shock: nature and causes 429 



Shell-shock PSORIASIS. Post-traumatic eczema. 



Case 313. (Gaucher and Klein, May, 1916.) 

A soldier, 28, came to the Saint-Louis skin clinic, May 15, 
1916, for leg lesions three months old. These lesions were 
cicatricial, squamous, irregular-contoured, and had developed 
following a wound. The lesions were eczematous. 

On the trunk, arms and elbow were lesions of psoriasis. 
These lesions had appeared after shell-shock. The man 
had been bowled over June 16, 191 5, by a marmite. The 
psoriatic lesions appeared shortly afterwards. The patient 
had never seen anything of the sort before. 

In this case the trauma provoked eczema; the emotion, 
psoriasis. Gaucher and Klein say that they have been 
struck by the recrudescence of psoriasis since the outbreak of 
the war, and remark, also, that there has been a relative 
increase of new cases since July, 19 14. 

There are cases of psoriasis following nervous shock, 
emotion and trauma. Sometimes the psoriatic lesion de- 
velops upon the scar of a wound. In the above case, as in 
the case of a woman of 25, a refugee from the Arras bom- 
bardment, the psoriasis began de novo and slowly developed 
immediately after the catastrophe of the Jena. Five, possi- 
bly six, out of eight cases totaled, appear, unlike the case 
sketched above, to have developed in cases either tubercu- 
lous or of tuberculous stock. 

Re psoriasis, Vignolo-Nutati remarks that this is a rela- 
tively frequent skin disease amongst Italian soldiers. He 
states that many of these cases are due to nervous shock. 
Some are related to wounds appearing near the scars. In 
all cases an emotional disturbance is the chief cause. Vig- 
nolo-Nutati had 86 cases of psoriasis in six months, 52 of the 
men coming from the front. Eighteen of the men said that 
they had not previously suffered from the disease. 



430 SHELL-SHOCK: NATURE AND CAUSES 



A sergeant gets the CROIX DE GUERRE and 
SHELL-SHOCK together: Transient deafness; 
later pseudohallucinatory electric bell ringing, rem- 
iniscent of civilian work; stereotyped movements, 
reminiscent of war experience. 



Case 314. (Laignel-Lavastine and Courbon, May, 
1916.) 

A sergeant, 24, had worked about Parisian hotels from the 
age of thirteen and a half. He won the croix de guerre and 
was evacuated for his wounds April 24, 191 5. 

It seems that he carried the remains of his company, 
which had been decimated the night before by a mine ex- 
plosion, on to the enemy trench, getting there first and facing 
three Germans, whom he beat down. At this time, gas 
shells began to rain about. Making a number of violent 
expiratory movements to get rid of the gas, he found him- 
self unable to progress on account of the fall of the shells, 
and sat motionless with his hands before his face. He was 
cast to the earth by an explosion, which at the same time 
blew off a revolver which the wounded lieutenant had passed 
to him. He sat up, and, observing that the soldiers had 
gotten the trench, went back to the lines, where he told his 
story. 

He then found that he was deaf, and wounded in the left 
leg. The wounds rapidly healed, but sundry other symptoms 
developed. He had a peculiar sensation back of the forehead. 
He could not think, read or write and was very weary. He 
got better in a few months, but disorders kept returning. 

His deafness had left him in about a fortnight, but when 
his hearing came back spontaneously, there were peculiar 
sensations. He constantly heard an electric bell, intense 
and continuous, like that of a French cinema advertising its 
films. The sounds seemed to begin in the ear and to run out 
as a sort of whistling. This sensation was preceded by 
buzzing and associated with noises like those of a musical 
triangle or a steam whistle. The noise kept up during wak- 



[shell-shock: nature and causes 431 

ing hours, but was often forgotten while he was at work. In 
sleep he heard nothing, except sometimes battle noises. 
August 20, 1 91 5, he was given the diagnosis: labyrinthine 
shock — hearing returned. 

About ten weeks after evacuation, when the headaches 
and thought blocking began to disappear, a generalized 
tremor, especially of the head, set in, which the patient 
called St. Vitus' dance. Then a peculiar gait began, which 
lasted several weeks and then transiently reappeared. Every 
few steps his legs would bend, and he could only walk for- 
ward in the attitude of a man who is concealing his height. 
After resting a few minutes he began to walk regularly again 
and the cycle began over again. He had to walk with two 
canes. If he felt some sudden emotion, or sometimes with- 
out any obvious reason, he would stop short and look straight 
ahead, with body bent, and arms before his face. This 
would last but a moment, whereupon he would walk again 
normally. 

When this anomalous walking disappeared, curious face 
movements and gestures began. If a strange person arrived, 
the forehead and eyebrows would contract, the eyelids would 
stand wide, which gave him an expression of surprise lasting 
a few seconds. At the same time the mouth would open and 
remain so for some moments. A forced expiration would be 
executed, suggesting a fish out of water. He would then 
imperatively strike the table with his fist, or the ground with 
his foot. 

Laignel-Lavastine and Courbon explain the anomalous 
movements as stereotypies due to secondary automatism. 
They are not convulsive, are not preceded by emotion or 
followed by a sense of relief, and are not tics. They are 
gestures and postures without present significance, but 
adapted to certain former circumstances. The electric bell 
effect is a sort of pseudohallucination, differing from true 
hallucinations in little except the absence of the externaliz- 
ing feature. The stereotypical movements are reproductions 
of things done in the battle, and the pseudohallucinations 
relate to the former hotel work of the soldier. 



432 SHELL-SHOCK: NATURE AND CAUSES 



Cinema worker, two days after being waked up by 
a shell, develops a nystagmiform tremor of eyes and 
tachycardia. Graves' disease? Tic (" occupational 
virtuosity ") ? 



Case 315. (Tinel, April, 1915.) 

A soldier was waked up with a start Sept. 22, 1914, by a 
shell burst. The man was not wounded or shocked, and 
merely felt a good deal moved. The next day but one he 
felt a little movement of his eyes, which was at first inter- 
mittent but in three or four days became continuous and 
troublesome. These movements were those of nystagmus, 
almost transverse and very rapid, and suggestive rather of a 
vibratory trembling than of a true nystagmus of the eye or of 
labyrinthine disease. When the patient fixed an object, the 
nystagmus would stop for a few seconds and then immedi- 
ately reappear. There had never been any vertigo, nausea, 
vomiting, deafness, ocular disorder, or disorder of equili- 
bration. During the tests for nystagmus, the morbid 
nystagmus would stop and be replaced by the normal nystag- 
mus which was obviously slower and more regular. The 
condition had persisted from September, 19 14, to the meeting 
of the Neurological Society, April 15, 191 5. The patient 
said he had become very emotional and got palpitations on 
the slightest occasion, such as a fast walk, going upstairs, or 
hearing a loud noise. There was also a slight vibratory 
trembling of the fingers and a permanent tachycardia (120- 
140 beats). Tinel regards the case as one of neurosis, due to 
a neuromuscular hyperexcitability comparable in some ways 
with that found in Graves' disease. 

Meige, in discussion, called attention to the fact that not 
every nystagmus is of organic origin and that there is a rare 
form of tic of nystagmiform nature. The victim in this case 
was an employee in a moving picture house, and very pos- 
sibly his occupation had permitted him to utilize what Meige 
speaks of as a "occupational virtuosity " of the eye muscles. 



SHELL-SHOCK: NATURE AND CAUSES 433 



Synesthesialgia : FOOT pain on rubbing dry 
HANDS, following bullet wound of leg. 



Case 316. (Lortat-Jacob and Sezary, November, 1915.) 

A foot chasseur was wounded, September 15, 191 4, low in 
the right thigh, a bullet entering outside the biceps tendon 
and emerging on the inner aspect of the leg, 4 cm. below the 
knee joint. He at once began to feel pains in the right foot, 
which grew swollen and red. The leg began to flex upon the 
thigh and, after straightening under anesthesia, was placed 
in plaster. An arteriovenous aneurysm developed in the 
popliteal space; operation, October 22nd, followed Novem- 
ber 1, by ligature. The pains in the foot grew better after 
this operation; but as soon as the wound was cicatrized they 
came back again as before. 

For seven months the foot pains remained sharp and con- 
tinuous, such that the man could not leave his bed. If a 
bright light struck his eyes, the pains grew much more 
marked, especially in the morning on awakening. The pa- 
tient found that when his hands were dry he could not use 
them because of the violent pains which rubbing them would 
cause in the right foot. Accordingly he kept putting his 
hands to his mouth to moisten them. Finally he kept a 
wet rag by him which he could pass from one hand to the 
other. 

The pain was what made walking difficult. Foot move- 
ments were only a bit less ample on the affected side than 
on the normal side. There was a general muscular atrophy 
of the lower extremity (30.5 : 34 about calf, and 40 : 49 
about thigh). Right knee-jerk more lively than left. Right 
Achilles jerk absent. Negligible disorders of electrical ex- 
citability in the territory of the right sciatic nerve. The 
skin of the foot was a little thin and pale; the temperature 
was low; and the nails had transverse striations. The 
pains grew gradually a little less marked, but if the room 
temperature was increased or lowered or if the foot became 
cold, the pains became extreme. Pressure on the popliteal 



434 SHELL-SHOCK: NATURE AND CAUSES 

space produced pain on the external border of the foot ; like- 
wise pressure on the calf. Lasegue's sign could not be tested 
for on account of the contracture of the flexors of leg on 
thigh. Due to the direct action of the bullet, there was an 
objective hyperesthesia of the dorsum and sole of the foot. 
The toes were anesthetic. A cold foot bath increased the 
pains, and a warm foot bath diminished them (contrary to 
experience in analgesias). 

This was a case of synesthesialgia in the right foot, 
brought about by rubbing dry hands, exactly as if there were 
a direct contact with the foot. Milder painful reactions were 
brought about by bright lights and loud noises; but on the 
whole, these other effects were insignificant. It must be 
remembered that the man was wounded and plainly had also 
organic nervous disorder. He sometimes complained of 
radiations of the pain up to the left hypochondrium, and 
sometimes he showed the classical sensation of "esophageal 
globus " (lump in the throat). In short, there was in him 
a special excitability of the nervous system which may partly 
explain the synesthesialgia. 



SHELL-SHOCK: NATURE AND CAUSES 



435 



k 



Shell-shock; burial: Clonic spasms; later, stupor 
with amnesia. 



Case 317. (Gaupp, March, 1915.) 

A reservist, 28 (laborer in civil life, of a nervous family; 
even before mobilization had attacks of weakness at his 
work or in the company of others) January 3 or 4, 191 5, 
fainted in the trench while shells were striking around him. 
On January 5 he was brought to hospital in deep stupor. He 
went to the reserve hospital at N. by hospital train, January 
8, and arrived at the Tubingen clinic January 18. 

A slip of paper stated that after burial in the trench he had 
been brought from the field unconscious. Clonic spasms of 
the upper part of the body are said to have occurred. At the 
reserve hospital in N., January 10, he was still unconscious, 
at times twitching his face and the upper part of his body, 
and once at night excited and delirious. 

At first in the clinic he was apathetic, speaking not a word, 
looking vacantly into the air as if lost in a dream. He went 
to the section passively, and lay passively in bed. 

In the examining room, he stood speechless with unemo- 
tional face, sometimes looking up to the ceiling, slowly 
scratching his head, failing to answer questions, although 
fixing his eyes upon the physician. He could not be com- 
municated with in writing, playing uncomprehendingly with 
the pencil or scratching his head with it. He would start 
with fright at a sudden noise or an unexpected touch. Some- 
times he would heave a deep sigh, grasp his head in his 
hands, or lay hold of his hair with a hopeless expression of 
face and shake his head to and fro. 

Next day, January 19, he made a few slow, low answers. 
He was found to be entirely disoriented and with associations 
impeded, although he could get out his name and residence 
with difficulty. Some of his color identifications were correct, 
such as red and green; some impossible, as yellow, brown, 
violet. A comrade who was called in and could speak the 
Cologne dialect, was talked with at first with difficulty, 



436 SHELL-SHOCK: NATURE AND CAUSES 

later more easily. Although the patient was visibly freer, 
he remained without apparent emotion, retaining a rigid and 
dreamlike expression of face. It was hard to find words, 
although objects were named correctly, and there was no 
paraphasia or agnosia. Vision and hearing were normal; 
walking, manual movements, eating were all undisturbed 
though slow. The patient had to be led to the toilet. It 
seemed as if all intellectual life was at rest, and that in the 
absence of impulses from without, there would have been 
complete apathy. It was made out that the patient thought 
he was still in the trenches. 

Next day, the stupor had decreased and the patient spoke, 
getting his bearings for a time. There was a complete 
amnesia as to the cause and duration of his condition. Dur- 
ing the next period, up to the beginning of February, 191 5, 
consciousness cleared and the apathy was replaced with 
anxiety, weariness, and a dull headache. 

During February, the patient gradually returned to his 
senses, and remained in a state of general nervous exhaus- 
tion. Amnesia was complete for at least two weeks of his 
life and recollections were fragmentary for the first three 
days of his stay in the clinic. He worked willingly in the 
garden with the other patients. On February 26, the patient 
was cured and went back to the reserve battalion in a much 
strengthened condition. 



shell-shock: nature and causes 437 



^ 



Battles (including liquid fire); eventually shell- 
shock : Hallucinatory delirium, mutism, asthenia — 
after a few days puerilism (history of convulsive 
crisis in adolescence) with regression of personality 
to late childhood. 



Case 318. (Charon and Halberstadt, November, 1916.) 
Puerilism (Dupre) appeared in a soldier, 21 (uncle and 
cousin insane; patient had difficulty in studies at fourteen 
and nervous spells for two years, with loss of consciousness, 
fall and convulsions probably at rare intervals; a student at 
eighteen) after he had taken part in a number of battles 
with the Chasseurs Alpins. He was exposed once to liquid 
fire July 21, 191 6. He entered the military psychiatric cen- 
ter at Amiens. Mental troubles had followed the bursting of 
a shell near him. He said a few words, such as, " Alsace; 
fire; blood; snow; it hurts." These phrases, spoken in a 
low tone, with an anxious appearance, eyes fixed, suggested 
hallucination. He seemed to be listening. Aside from the 
isolated words above mentioned he showed complete mutism. 
There was physical weakness, difficulty in walking without 
support, exaggeration of patellar reflexes, pains in the head 
and limbs. After several days, he said, "Milk; bread." 
After this the anxiety and the slow and difficult walking dis- 
appeared, whereupon the puerilism appeared. 

Now the soldier began to run instead of walking. He 
galloped and gamboled like a child imitating a horse, or he 
would sit on a board seeming to paddle. He would skip 
along the halls. The puerilistic phases were rather brief and 
for the most part he lay in bed. There was still a certain as- 
thenia. He made little paper boats in bed, keeping them in 
a small metal box along with bits of bread, looking glass and 
the like. If a gesture was made to take them away, he 
would protest and press the box to his breast, looking childish 
and anxious, and if the box were taken he would weep hot 
tears. Sometimes he would stick out his tongue at the 
attendants. His mother came to see him and afterwards he 



43^ SHELL-SHOCK: NATURE AND CAUSES 

would say, "Mamma told me to be good, to eat well, to get 
well and to go home." He would use childish grammar, — 
"Me eat much." Asked why he had hollowed out a small 
hole in the wall of the room, he answered, "I did it for fun, 
but I will not do it any more. Mother doesn't want me to." 
The patient was unwilling to answer a question correctly; 
would sometimes answer incorrectly at first and correctly 
afterward. 

It appears that the man had adopted the language, occupa- 
tions and attitude of a child, showing a regression of person- 
ality ten to twelve years backwards. There was a neurotic 
basis in the convulsive crises of adolescence. On the basis 
of this predisposition following shock there appeared an at- 
tack of confusion, upon which, several days later, super- 
vened ecmnesic phenomena of hysterical nature assuming all 
the features of puerilism. 



SHELL-SHOCK: NATURE AND CAUSES 439 



Bomb-dropping from airplane; unconsciousness: 
Battle dreams. Leaves of absence failed to relieve. 
Episodes of dizziness and fugue. 



Case 319. (Lattes and Goria, March, 1917.) 

M. Alessandro, Class '79, baker (father a drunkard; 
brother an idiot, in asylum), had typhus in youth, and as a 
boy had periods of intense "pavor nocturnus," but no con- 
vulsions. He enjoyed good health in the army before the 
following event: 

On July 13, 1915, a bomb, dropped by an airplane, fell 
near an Italian soldier, killing many comrades, and throwing 
the man to the ground unconscious. He awoke several 
hours later at a hospital in a stunned condition. During 
the night, under the influence of terrifying dreams, he would 
leave his bed to look for enemies who, it seemed to him, were 
throwing stones and firing. He managed to grasp a rifle and 
fire at the images he saw. He was given a 60 days' leave of 
absence during which he did not improve; and then again 
90 days' furlough, which he spent at his home, where terrify- 
ing dreams, tremor of limbs and asthenia continued. 

He came under observation February 10, after his second 
leave. Nutrition fair. Insomnia. Constant terrifying 
dreams. Coated tongue. Tremor of hands, head, body, 
ceasing during voluntary movements. Episodically he had 
spells of dizziness followed by absent-mindedness, whereupon 
he wandered aimlessly about, of a sudden becoming aware of 
being in a place, but not knowing how he came there. 

Special senses intact. Several points of cutaneous hyper- 
esthesia, particularly mammary and pseudo- ovarian on the 
left, pressure whereon provoked a lively emotional reaction 
with acceleration of pulse, redness, lacrimation. Knee re- 
flexes lively, cutaneous reflexes normal, except the plantar 
which were very lively. Restless, hyperemotional, he wept 
for insignificant reasons and wanted to leave hospital for fear 
of dying there. He was discharged unimproved after a fort- 
night. 



440 SHELL-SHOCK: NATURE AND CAUSES 



Nostalgic temperament; depression on entering 
service ; rheumatism. A box falls from an airplane 
near by: Fear and tears; later depression, nos- 
talgia, dreams, hyperthyroidism. 



Case 320. (Bennati, October, 1916.) 

An Italian private in the infantry was recalled to military 
service. He was a small farmer, and being disposed to home- 
sickness, grew depressed from the day he left for service. 
His sleep was disturbed, he was greatly affected by the wet 
and damp of the trenches, and was in a state of continual 
fear. Finally, pains, hypersensitiveness, and fever de- 
veloped. 

As an enemy airplane passed over one day, a box fell at 
the man's feet and threw him into a profound fear with 
tears. He was conducted to a tent to rest; his regiment 
was shortly sent to the rear, and he remained on active ser- 
vice for a few days despite the fever and pains. Finally the 
swelling of his leg compelled him to take to bed. (Fatigue in 
antebellum life had always shown itself in aches of the legs.) 
He had now been in active service about a month and his 
homesickness overcame him. He was in a state of deep 
physical and mental depression. It was not his own troubles 
so much as those of his family which preoccupied him. His 
knees hurt him so that he had to weep; or if Sardinia was 
mentioned, he cried, and said, "Oh, how I love Sardinia !" 
He grew fatigued very easily. He had many dreams about 
Sardinia, his father, and the war, especially dreaming about 
being wounded in the legs (question of being stimulated by 
the joint aches.) The reflexes were normal, though slight 
tremors set up in the legs after testing. The thyroid gland 
was somewhat swollen, and it appears that the patient had 
noticed this five days before entering hospital. The patient 
was rather vagotonic; pulse-rate stood at 56; oculo-cardiac- 
reflex, 56-84; Mannkopf negative; Thomayer and Erben 
marked (56-88 and 88-60); von Graefe marked; Stellwag 
present. 



shell-shock: nature and causes 441 



A shell pitches without bursting : Unconsciousness ; 
stupor ; MAMA MIA ! ; oniric delirium ; amnesia. 
Recovery in five weeks. 



Case 321. (Lattes and Goria, March, 1917.) 

An Italian soldier of the Class of '95, a mechanic (mother 
cardiac; as a boy, pains in joints and heart; since boyhood, 
no illness), had a big Austrian shell pitch near him, July 23, 
19 1 5. The shell failed to explode and injured no one. The 
patient, however, fell to the ground, unconscious, and re- 
mained in the camp hospital for two days, quite immobile. 
This event followed an advance by his company under very 
fatiguing circumstances without sleep for a period of four 
days. 

July 26, the patient was observed in profound stupor, non- 
reactive, constantly and monotonously repeating the phrase, 
Mama mia!, with fixed gaze and smiling as if at visions. He 
swallowed food. The pupils reacted poorly to light, and the 
cornea and nasal mucosa seemed anesthetic. The tendon 
and skin reflexes were lively. The muscles were hypotonic; 
bradycardia, 56; no control over feces or urine. 

July 27-28, restlessness at night, gasping movements, and 
poses of terror. 

July 29, he called for his mother, who had been dead for 
several years. He was still stuporous and insensible. 

From August 1 to 10, he improved slowly and became 
able to carry bread to his mouth after it had been put in his 
hands. He still did not speak and made signs when he 
wished to urinate or defecate. Pulse 50-60. 

August 12, the patient began to react to intense light and 
to pain stimuli, as well as to pressure. He ate voraciously. 

August 15, visual stimuli were responded to, the pulse had 
risen to 80, the skin reflexes were no less lively. There be- 
gan to be terrifying dreams at night, with motor reactions. 

August 17, the patient looked about more alertly, promptly 
seeing bread when placed in the center of the field of vision 
and saying words to the man who might try to remove the 



442 SHELL-SHOCK: NATURE AND CAUSES 

bread. He did not yet react to acoustic stimuli, nor was 
there any other change up to August 21. 

August 22 a notable improvement set in. The hearing 
was now slightly diminished, questions were answered after 
a brief refractory period. After a few questions, however, 
a state of exhaustion would ensue, which would disappear 
only after a short rest. There was amnesia for the entire 
period following the day of his departure for the front, May, 
191 5. At this time, instead of eating voraciously, he showed 
anorexia. The skin and tendon reflexes, instead of being 
lively, were now dull. There still were battle dreams of 
enemies trying to kill him. 

August 25, there was an area of hypesthesia on the inner 
aspect of the right thigh, but otherwise no disorder of sensa- 
tion. The pulse stood at 80 and there were no other neu- 
rological phenomena. 

August 31, the patch of hypesthesia of the thigh and the 
retrograde amnesia disappeared. There was still a slight 
diminution of hearing. The accident of the non-exploding 
bomb could now be recalled, but there was a memory gap for 
all facts up to the latter part of August. 

September 2, dreamless sleep; no signs of abnormality 
except a slight diminution of hearing. Discharged, well. 



SHELL-SHOCK: NATURE AND CAUSES 443 



Jostled carrying explosives; no explosion; uncon- 
sciousness : Deaf mutism and foggy vision. Grad- 
ual recovery from these symptoms. Then, on ris- 
ing from bed, camptocormia. 



Case 322. (Lattes and Goria, March, 191 7.) 

An Italian of the Class of 1891 (convulsions and pains in 
the spine, with rigidity, as a child; typhoid fever at 18; 
brother sickly, neuropathic; mother subject to periodic con- 
vulsions; father alcoholic and nervous), on the night of 
November 26, 191 5, was carrying a number of tubes of ex- 
plosives. A comrade stumbled and fell over the soldier, 
who fell to the ground unconscious. None of the glycerine 
tubes exploded, and none of the soldiers round about were 
hurt. 

The man regained consciousness at the camp hospital, 
but remained deaf mute and also impaired as to vision. It 
was as if a screen of fog lay between him and objects seen. 

During fifteen days of observation at the camp hospital, 
he had terrible war nightmares. The mutism, the visual 
disorder, and the deafness then gradually disappeared with- 
out special treatment. 

However, when the patient rose from bed, it was found 
that his lumbar vertebral column was stiff. He walked bent 
forward and was unable to bend or straighten the back. 
There was a hyperesthesia along the vertebrae, especially on 
pressure. X-ray examination showed no bone lesion. The 
larynx and cornea were sensitive, and the plantar reflexes 
were absent. The abdominal reflexes were present. The 
pupils reacted to light and accommodation. There were 
two areas of analgesia in the nipple regions. The expression 
of the patient's face was relaxed and drooping. 



444 SHELL-SHOCK: NATURE AND CAUSES 



A heavy cannon slides and grazes a man : Uncon- 
sciousness; stupor; amnesia (anterograde am- 
nesia persistent). Complete recovery in less than 
seven weeks. 



Case 323. (Lattes and Goria, March, 191 7.) 

An Italian soldier of the Class of 1895, a peasant (family 
healthy; non-alcoholic; good scholar) was, July 19, 191 5, 
helping drag a heavy cannon up hill. The big gun slid, hit 
several men, and grazed the patient, making a slight abra- 
sion on his leg. He immediately lost consciousness, and 
arrived at the camp hospital in a stupor, which lasted so 
long that catheterization was necessary. 

A week later he was observed in hospital, immobile and 
non-reactive, with a swollen abdomen and fecal impaction. 
The pupils were widely dilated and reacted poorly to light. 
The corneal reflexes were absent, and the nasal mucosa was 
anesthetic. Pulse 50. The patient failed to eat. Next 
day there was no change in his condition. He was quiet 
throughout the night. 

On the morning of July 29, a number of answers were 
obtained to questions put in a loud voice, though he was 
unaware of much more than his name, being ignorant of the 
name of his country, his age, his division, where he had come 
from, what had happened to him, or where he was. He had 
now begun to eat spontaneously. 

During the following days, up to August 4, the amnesia 
gradually dissolved for the facts before the trauma. He 
remembered having been greatly frightened at the time of 
the accident but could not remember the accident itself, and 
the gap for subsequent events was still complete. The 
pharyngeal reflex was still poor. August 5, he began to re- 
member the details concerning the accident. About the 
middle of August there was no longer any diminution of 
hearing and ideation became more free and rapid. 

September 4, he was discharged, well. 



SHELL-SHOCK: NATURE AND CAUSES 445 



Shell explosions SEEN : Emotion ; insomnia. Ar- 
tillery HEARD twelve days later: " finished off." 



Case 324. (Wiltshire, June, 191 6.) 

A lance-corporal, 36, had had a nervous debility four or 
five years before the war, caused by an overstudy of music. 
He had not stopped work at that time, but suffered from de- 
pression, anorexia, and insomnia, lasting for some weeks. 

The lance-corporal got on well at the front for 11 weeks, 
until finally eight shells pitched near him. Although he was 
unhurt, he began to suffer from anorexia, insomnia, and de- 
pression. While in billets 12 days later, some English artil- 
lery became heavily engaged, whereupon "The noise promptly 
finished me off." The insomnia, depression, and anorexia 
became more marked, and the patient could not sleep unless 
heavily drugged. 



446 shell-shock: nature and causes 



Shell-shock: Emotion. More shells: Insomnia; 
war dreams. Head tremor and tic, two weeks 
after initial shock. 



Case 325. (Wiltshire, June, 1916.) 

The psychic trauma is, according to Wiltshire, more im- 
portant than physical trauma in the following case of a ser- 
geant of infantry, 28, a man without neuropathic taint. 
This man had been nine months at the front and through 
Mons, but had been quite well until three weeks before com- 
ing to hospital. 

" Twenty- three days ago, I was issuing rations when they 
got the range of us — and killed the other chaps. I got 
blown away and knocked over. I saw everything — fellows 
in pieces. Then a second shell came. I got lifted and 
knocked about ten yards." Then he began to shake but 
carried on. 

Two days later, "Shells dropped on the dug-out and killed 
the other chaps. I have not slept properly since this. If I 
go to sleep, I wake up seeing people killed, shells dropping, 
and all kinds of horrid dreams about war." One or two of 
the men killed had been pals. 

A fortnight after the first incident, while in a base hospital, 
head-shaking began. The patient would jump at the least 
sound. There were spasmodic tic movements with the ex- 
tension of the head, protrusion of lower jaw, and contraction 
of occipitofrontalis muscle. Sometimes the left shoulder 
girdle was affected in the same way. There was a slight fine 
tremor of hands and eyelids and difficulty in keeping the 
eyes fixed on an object. 



SHELL-SHOCK: NATURE AND CAUSES 447 



Hyperthyroidism, hemiplegia, irritative symptoms 
after exhaustion (by heat?). 



Case 326. (Oppenheim, February, 1915.) 

A man (not previously nervous, no faulty heredity, heat- 
stroke August 21) suddenly fell down in a great heat, after a 
fatiguing march, and remained unconscious for several hours, 
waking with vertigo, headache, paralysis of left side, vomiting, 
and twitching of the face. On September 23, admitted to 
reserve hospital. Knee phenomenon increased. Urinary 
retention; catheter used. Speech disturbance, facial twitch- 
ing. Vomiting had stopped September 10. Catheteriza- 
tion could be avoided through warm sitz-baths. October 30, 
on sitting up, occipital pain and vertigo. November 15, 
urinary symptoms improved Also improvement otherwise. 
December 1, gait vacillating and uncertain. Headache. 
Admission to nerve hospital, December 3. Here complained 
of twitchings in the frontals and corrugators. Wide palpe- 
bral gaps. Rare, or absent, movements of lids. The 
extended hands showed active, rapid tremor. Tendon phe- 
nomena increased in the arms and especially in the legs. 
Abdominal reflexes increased. Active tremor in the legs. 
Gluteal tremor. Very pronounced Graves' symptoms. Syn- 
dactylism very pronounced in the feet, between second and 
third toes. Later on, improvement under half-baths, etc. 
Worse after ten days' leave of absence, especially marked 
increase of tremor (rest tremor), augmented on movement. 

Re heat stroke, Wollenberg has called attention to the 
effect of the heat of the summer months upon German sol- 
diers. Cases of heat stroke have not been rare in the German 
army. About half the cases have convulsions or epileptoid 
seizures, as well as tremors and nystagmus. About a quarter 
of the cases have shown confusion and delusions, with anxiety 
and mania. A degree of mental impairment has followed a 
number of these heat strokes, together with sundry signs of 
organic disorder, such as reflex changes, pupillary changes, 
and difficulty in speech. 



448 SHELL-SHOCK: NATURE AND CAUSES 



Forced marches; skirmishes; rheumatism: Gener- 
alized TREMORS. On the road to recovery in six 
months. 



Case 327. (Binswanger, July, 191 5.) 

A German letter carrier, 27, entered the war at the outset, 
made forced marches in great heat, was in a number of skir- 
mishes and in the capture of Namur, and fell ill early in 
September, with swollen and painful right foot and rheumatic 
pains in knees and shoulders. He was put on garrison duty; 
but the rheumatic pains in the joints increased toward the end 
of September, and he was treated in hospital for rheumatism. 

He became able to walk only in the second half of Decem- 
ber, marked tremors affecting the whole body. His bodily 
condition had been good. He slept well, and while at rest in 
bed he felt entirely well; but upon every attempt to get up 
and put his feet down, these violent trembling motions would 
always reappear. Treatment by hydro- and electrotherapy 
remained entirely unsuccessful. February 8 he was trans- 
ferred to a nerve hospital. 

He had been in the postal service from 1903. He was of 
normal bodily and mental development and had had no 
previous illnesses. His military service had been executed 
from 1909 to 191 1. He had always been a passionate smoker 
but had not abused alcohol. His mother is said to have been 
for some time paralyzed, following a fright. 

Physically, the patient was a slender but strongly-built 
and fairly well-nourished soldier. The first sound at the 
apex of the heart was rough and impure, and the heart was 
somewhat enlarged to the left. The pulse was irregular, 
106. The arteries were somewhat stiff. Neurologically, 
there was a marked dermatographia of comparatively long 
duration. The periosteal reflexes were increased; the deep 
reflexes could not be properly examined. The whole leg 
trembled and heaved unsuccessfully on attempts to raise it 
voluntarily. After even a slight stroke on the patellar 
tendon, the trembling became excessive and irregular, and 



SHELL-SHOCK: NATURE AND CAUSES 449 

the leg passed into a heaving spasm which would outlast 
the percussion for some time. The patellar clonus could 
be obtained with the knee extended. The shaking move- 
ments were somewhat more marked on the right than on 
the left side. Similar phenomena occurred when the Achilles 
reflexes were being examined. The triceps reflexes on both 
sides were increased but there was no tremor or spasm of 
the arms. The plantar reflexes were very lively, and fol- 
lowing these reflexes appeared tremors of the legs. When 
the spinous processes of the vertebral column were per- 
cussed, a general shaking spasm appeared. Tactile sense 
was everywhere normal, but the pain sense was increased. 
Upon slight pin-pricks in the skin of the legs, there would 
occur a marked shaking spasm of the leg, passing directly 
to the other leg. These phenomena were more marked on 
the right side than on the left. When sitting upon a chair 
with back supported, a slight tremor would appear when 
the hands were raised and stretched out, more markedly on 
the right side than on the left. Movements of the arms were 
normal. However, the hand-grasps were: right, 105; left, 
80. In dorsal decubitus the movements of the leg were 
performed comparatively well at first, but after a few repe- 
titions, the shaking spasm would occur on both sides, and 
the movements would become very awkward. The heel- 
to-knee test would then fail. If the patient were put on his 
feet, he would immediately fall into spasms, first in the right 
leg, then in the left. The trunk would now be involved, 
and soon the arms, whereupon the whole body, with the 
exception of the head, would be seen trembling and shaking, 
and the patient would fall forward, trying to get support by 
leaning against a wall, seizing a chair, or sinking down slowly. 
The spasms disappeared at once in dorsal decubitus and in 
sitting with supported back. Outward irritation by the 
acoustic, optic or tactile avenues would bring out spasms in 
the legs, always more markedly on the right side than on the 
left. Psychic irritations would cause spasms. The muscles 
of the limbs were held in great tension, the flexors and ex- 
tensors being alternately affected. When the patient was 
moving along a wall with a difficult, swaying gait, his efforts 



450 SHELL-SHOCK: NATURE AND CAUSES 

reminded the examiner of the attempts of a heavily intoxicated 
man to walk. Upon attempts to create passive movements 
of the lower limbs, severe shaking and trembling movements 
set in, followed by a general spastic tension of the leg muscu- 
lature such that it could not be further flexed or extended. 

The patient was put in the psychiatric section, as too 
seriously ill for the nerve hospital. He improved after a 
few days, being then able to walk without much support 
although still with some shaking and tremor. If his atten- 
tion was diverted, passive movement of the leg could be 
carried out without developing spasm. He was treated in a 
room by himself with removal of all outward irritation. 
His legs were treated for an hour, three times daily, by 
means of moist packs. On account of complaints of insom- 
nia he was given small doses of hypnotics. 

The main thing here, according to Binswanger, is the 
psychotherapy. The patient was told almost daily in the 
course of conversation, first, that the illness was being 
cured; secondly, that upon recovery he would be employed 
in the future only on the postal service. He was told that 
he would have to avoid marked physical exertion, of course, 
but that he still would be fit for office work and could serve 
the fatherland in this way. Still he could not be trans- 
ferred back to the hospital, he was told, unless he became 
entirely well, so that he could move with perfect freedom. 

February 23 the patient was performing daily exercises in 
walking and standing; the spasm became very slight on 
standing, and often would entirely cease, but it remained 
still plainly present in the legs; the trunk and arms were 
free. External irritations were now less prone to excite 
spasm. Sleep became quiet and dreamless. He was trans- 
ferred to the nerve hospital, able to move about freely in 
house and garden and only tremulous after long walks and 
considerable bodily and mental fatigue. He was given a 
week's furlough home. He wished very much to get into 
the postal service; at the time of the report he had not 
attained this goal. He had renewed attacks of trembling 
upon exertion, and was transferred at the end of June to a 
convalescent home. 



SHELL-SHOCK: NATURE AND CAUSES 45 1 



Shell-shock ; emotion : Hyperkinesis, fear, dreams. 



Case 328. (Mott, January, 1916.) 

A private, 21, was with 30 men carrying sandbags in the 
daylight, under shell fire. He was thrown into a deep hole 
by an explosion, climbed out, and saw all his mates dead. 

He was admitted to the Fourth London General Hospital, 
June 20, 1 91 5, having been at Boulogne for a fortnight. He 
was lying in bed on his back, making continuous jerky lateral 
movements of head, and movements of arms, especially of 
the left arm. He was groaning slightly, now and then raising 
his eyelids with a staring expression of bewilderment and 
terror. He was able to mutter answers to questions. He 
would occasionally raise his right hand to his forehead. If he 
was observed, these movements became exaggerated. They 
ceased in sleep. He muttered even when unobserved. He con- 
tinually said, "You won't let me back." Asked as to dreams, 
he replied, "Guns." Voluntary movements were made, which 
prevented obtaining reflexes. When his pupils were to be 
examined by a man in uniform, he showed a marked facies 
of terror; his pupils were dilated; the eyes opened wide, the 
brows were furrowed, and there was an anxious scowl. The 
flash of an electric light produced the same effect. 

June 24 the patient was much better. He said the ex- 
plosion which had killed his friends after he had been only a 
few weeks at the front, was the first serious event in his 
service. He kept seeing it again, with bright lights and 
bursting shells. Sometimes he would hear the men shouting. 
In dreams he both saw and heard shells and men. There 
was pain in the back and right side of the head. 

June 26 he was improved but still had pain in the back of 
the head, especially when trying to remember, and a slight 
tremor of the hands. He had been given hot baths at 
Boulogne on account of being very cold and shivering. He 
had always felt sick at the sight of blood. He was boarded 
for Home Service six months after admission. 



452 SHELL-SHOCK: NATURE AND CAUSES 



Shell fire and barbed-wire work : Tremors, anesthe- 
sias, temperature and pain hallucinations. 



Case 329. (Myers, March, 1916.) 

A corporal, 39, had been working under shell fire at 
barbed- wire entanglements. The man was big and robust, 
but much depressed, complaining of noises in the head, 
pricking pains, unsteady legs, fatigue, irritability, loss of 
confidence. He showed tremors of arms and legs on move- 
ment, and stood unsteadily with eyes closed. He said: " My 
legs have been very unsteady, especially when some one is 
looking at me. They must have thought me drunk at times.' ' 

The head and tongue were tremulous, the knee-jerks 
exaggerated, the soles insensitive to touch and pain; but 
sensibility to deep pressure was retained. There was a 
gradual return of right answers on further trials, aided by 
comparison with effects of stimuli applied to the dorsum of 
the foot. Though he gave correct replies on heat and cold 
tests over the arms, he gave wrong answers over the dorsum 
of the feet, less often over legs, sometimes over thighs. 

Later during examination, the feet became tremulous. 
He felt a " silly childish fear," and his hands began to feel cold 
and clammy; whereupon he began to reply hot or cold when 
the tubes were not applied at all (temperature hallucina- 
tions). There were apparently pain hallucinations in the 
soles and errors in response to the compasses. 

Re the temperature hallucinations noted by Myers, these 
are to be distinguished from true vasomotor disorders. 
Babinski believes that he has definitely established that, 
though hysteria may cause a slight thermo-asymmetry, yet 
never a definite vasomotor or thermic disorder. 

Re hysterical pains, the most frequent are probably those 
of hysterical pseudo sciatica, in which true signs of sciatica 
are absent, namely, (1) loss of Achilles jerk, (2) scoliosis, 

(3) Lasegue's sign (pain on thigh flexion with leg extension), 

(4) Neri's sign (with trunk bent forward, affected knee 
flexed), and (5) Bonnet's sign (pain on thigh adduction). 



SHELL-SHOCK: NATURE AND CAUSES 453 



Shell-shock: Emotional crises; twice recurrent 
mutism ; amnesia. A comrade in the same explo- 
sion gets off with transient phenomena. 



Case 330. (Mairet, Pieron and Bouzansky, June, 191 5.) 

December 15, sitting back of a wall were three minor officers 
and an homme de liaison, when a 105 shell punctured the wall 
and burst, killing one and wounding another severely. One 
of these, a sous-lieutenant, lost consciousness for a quarter of 
an hour and had some severe headaches for a few days, but 
nothing more. The other, the homme de liaison, was found 
standing, bewildered, looking at the dead. When his name 
was called, he jumped and started off, weeping and crying 
out. 

When caught, he was still somewhat clear, recognized his 
superior officer, answered yes and no, but kept asking, 
"Where is the other? " Next day he kept weeping and said 
not a word. 

He was evacuated through a series of hospitals and was 
sent to convalesce with his sister at Montpellier, having now 
got back his speech. He had a seizure of fear in the street 
and was picked up by the police and was carried to a general 
hospital January 21. Here he could not speak, could hardly 
write, being unable to find his words. He walked slowly, 
bent over, eyes abnormally wide open, with a look of terror. 
The lighting of a match made him start off weeping. The 
symptom picture included tinnitus, vertigo, deafness, some 
reduction of the visual field (especially on the left side), 
hypesthesia and hypalgesia on the left side, hyperalgesia on 
the right, painful points (epigastric, inguinal, supra and infra 
mammary left), reflex, muscular and tendon, hyperexcita- 
bility on right side, jactitation, impairment of recollective 
memory, complete memory gap for the accident and every- 
thing thereafter, retentive memory reduced, imagination 
impaired, nightmares (awaking with a start). 

A few days later he was able to pronounce his name with 
difficulty and to say yes and no. February 4 there was an 



454 SHELL-SHOCK: NATURE AND CAUSES 

appendicular crisis, whereupon mutism became absolute 
again and lasted into May, despite suggestive therapy. 

May 10, improvement in memory for things before the 
accident grew better, nightmares had become less frequent, 
the jactitation had continued. 

There was no neuropathic predisposition in this case except 
infantile convulsions in two sisters, followed by nervous crises 
in one. 

Re appendicular crisis, which was the occasion of a relapse 
in mutism, see remarks under relapses under Case 292. 

Re mutism, Babinski counts mutism, hysteria major, and 
rhythmic chorea as so characteristically hysterical that no 
nervous disturbance of an organic nature can resemble them. 
The description of hysterical mutism is due to Charcot. 
According to Babinski, mutism is just as curable as hysterical 
deafness, and perhaps more curable. Yet mutism persists 
unchanged for many months unless it is treated properly by 
some form of suggestion. "It may be almost said that a 
subject suffering from speech defect, who nevertheless suc- 
ceeds in making other people understand by all sorts of 
varied and expressive gestures the circumstances of his condi- 
tion, is a hysterical mute and not an aphasia" According to 
Babinski, no true case of hysterical aphasia has been pub- 
lished since the beginning of the war; all the cases have been 
cases of mutism. 



SHELL-SHOCK: NATURE AND CAUSES 455 



Shell explosion; fainting: Hysterical crises of 
emotion ; fright at a frog in the garden. Hereditary 
and acquired neuropathic taint. 



Case 331. (Claude, Dide and Lejonne, April, 1916.) 

A lieutenant, 28 (mother nervous; father had nervous 
spells at fifteen ; patient himself nervous as a child) , was under 
a great moral strain at the outbreak of war, and was utterly 
exhausted in a hard battle that lasted more than twenty-four 
hours. 

A shell burst near him September 25 at the Somme, where- 
upon he fainted. He was evacuated to Amiens for three 
weeks; kept his bed; somnambulistic; subject to nervous 
crises. 

He passed to the hospital of Ferte-Bernard for a month, 
the crises becoming more frequent. He was sent to a con- 
valescent dep6t for three days, thence for three months to 
La Plisse; got better; lived at home, but went to a show 
where they played the Marseillaise, was profoundly moved 
thereby, and had more crises; accordingly went back under 
medical care and finally to his depot, where, upon seeing his 
old comrades, he had more crises, and was finally evacuated 
to the neurological center of the Eighth Region. 

He there seemed mistrustful when asked to tell his story. 
There was a noise of cannon, whereupon he got up, ran in all 
directions in the garden, bumping into trees in the greatest 
terror, yelling, "There they are! "; gesticulating, soliloquizing: 
"Bomb! Shell! Bayonet!" His pulse was rapid. After he 
was calmed down, he began to talk again in a very clear, 
distinct, somewhat tremulous voice. A metallic sound made 
him shudder and cry out, "The drums !" and another scene 
of rushing about followed. 

In the consulting office he wept. Battle dreams and night- 
mares, soliloquies and terror, seminal losses, occurred during 
the next few days. 

August 4, while alone in the garden, he heard a noise, went 
toward it and spied a frog, whereupon he had another crisis 



456 SHELL-SHOCK: NATURE AND CAUSES 

of fear and emotion. He got another lieutenant, and both 
returned, sticks in hand. Pointing to a hole in the earth, 
Lieutenant A. said, "Trenches! There they are!" "What? 
Who?" said Lieutenant B. "The Bodies!" said Lieutenant 
A. Whereupon Lieutenant B also saw them and cried out 
bravely, "Go away!' However, the second lieutenant im- 
mediately saw that he had been the subject of suggestive 
hallucination. 

Fifteen days of calm followed, during which the lieutenant 
became more sociable and grew better having no more 
crises. 

Four other cases of " hysteroemotive nature " are reported 
by Claude, all of them showing a special constitutional basis 
before the war. In the differential diagnosis, alcoholism, 
cyclothymia, obsessive psychosis and occasionally systema- 
tized delusional psychosis may be considered. There were 
occasional stereotypical features in the cases, but of a very 
fugitive nature. Dementia praecox is hardly to be con- 
sidered. 

Re "hysteroemotive" cases, Babinski holds that the claim 
of emotion as a single factor capable of causing hysteria by 
itself, is a false claim. To be sure, the patients themselves 
may give accounts which lead to the idea of an emotional 
hysteria. Dide, one of the authors of the above case, states 
that functional disorders occur only in subjects whose emo- 
tional tone has been relaxed. The heaviest bombardments 
are not in line to produce these disorders when the morale 
of the troops is good. The bloodiest affairs may leave no 
single case of nervous disorder when the morale is good. 
Dide found in a whole year's work but a single functional 
case, — an oniric delirium, following a trench mortar explo- 
sion. Roselle and Oberthiir also state on the basis of in- 
tensive experience, that large projectiles do not cause any 
intensive emotional reactions. Clunet's observations upon 
the shipwrecked La Provence II, quoted by Babinski, run in 
the same direction. It will be noted that the five cases called 
"hysteroemotive" showed a special constitutional basis 
antebellum. 



SHELL-SHOCK: NATURE AND CAUSES 457 



War strain; slight wound; burials; shell-shock: 
Neurosis with anxiety ; war dreams ; apparent re- 
covery. Relapse with depression. 



Case 332. (MacCurdy, July, 1917.) 

A man, 2*] (normal mischievous boy, successful in work, 
unmarried, shy with women), enlisted October, 1914; adapted 
himself well to training; at first enjoyed his work, though 
later bored with routine; and in February, 1 91 5, went to the 
firing line in France. The first shell- fire experience made 
him break into a cold sweat with fear and slowed him down 
for a time. However, he enjoyed the active operations until, 
after eight months in the trenches, he was invalided home with 
nephritis. After four months' convalescence he was recom- 
mended for a commission, obtained after two months' training. 
After two further months in the regimental dep6t, he went 
back to France as lieutenant in June, 1916, plunging into four 
months of heavy fighting on the Somme, in which he was 
wounded slightly once and was one day buried three times by 
earth from shell explosion. The last time he was buried he 
was unconscious for ten minutes and was relieved for three 
days. He got frequently knocked out for short periods by 
shell concussion. 

At the end of October, 1 916, he was sent to the Ypres section, 
where he worked with a pioneer battalion that buried many 
dead. After a month of this pioneer work he became mildly 
depressed ; fatigue set in, and now for the first time he began 
to jump nervously when the shells came over. To counteract 
this nervousness he began to drink and in a fortnight de- 
veloped insomnia. The Somme front scenes kept constantly 
in mind as he tried to sleep. He felt as if he had to go up to 
the trenches next day and that he did not want to go. There 
were hypnagogic hallucinations of trenches and shells, recog- 
nized as imaginary and productive of no fear. Week by week 
he became more nervous, became unable to locate shell falls, 
and felt as if they were all coming at him. Early in 191 7 he 



458 SHELL-SHOCK: NATURE AND CAUSES 

had taken heavily to drink and grew greatly fatigued in the 
struggle to prevent betraying his fear to his men. The horror 
at bloodshed, to which he had long since become accustomed, 
reappeared. He actually wished that he might be killed. 

He carried on until March, when one day on a raid seven 
men were killed around him and he was immediately there- 
after buried. He reported sick and was found to be some- 
what febrile. He carried on for two more days; had to 
report sick again; was sent to hospital and for two or three 
weeks had bad headaches back of the eyes and a sleep inter- 
rupted by sudden wakings with a start. Nightmares now 
began for the first time. They dealt with the Somme front, 
merciless shelling coming nearer and nearer. Finally, he 
would wake with a shriek when a shell landed on top of him. 
In the day time any noise would be interpreted as a shell. 
Hypnagogic hallucinations of Germans entering the room 
appeared. After a little over a week in French hospitals he 
was transferred to London; grew better; was sent to a 
hospital in the country where outdoor exercise and recreation 
helped him. 

Two weeks later the death of one of his best friends de- 
pressed him a good deal. He failed in an attempt to sing at 
a concert, and then grew much worse, witji the old dreams 
every night and hypochondriacal complaints of sweats and 
loss of weight. He was convinced that he was physically 
and nervously a permanent wreck. 

According to MacCurdy, this case is a typical case of war 
neurosis of the anxiety type, except that a relapse with de- 
pression is somewhat atypical. 

Re anxiety, Lepine counts trauma as one of the most 
important factors. The reduction of morale in physically 
injured cases may at times require their rapid withdrawal to 
a safety zone. The delirium of the physically injured some- 
times takes on a melancholic tinge. Fatigue, loss of sleep, 
and cold are other factors of a physical nature. Among 
the moral factors, Lepine thinks responsibility (for certain 
dmes scrupuleuses) is hardly less important than the factor 
of felt danger. The contacts of highly cultivated men with 
the rougher soldier element, may also count, as well as the 



SHELL-SHOCK: NATURE AND CAUSES 459 

separation from home and friends, and the factor of despair 
concerning the ending of the war. 

Re sexual influences, the factor of sexual continence, though 
it may have some importance in producing morbid anxiety, 
seems to have less importance under war conditions, when 
self-preservation is more in the eye than the sexual life. On 
the whole, the pre-existent emotional constitution (Dupre) 
is of greater importance. A previous wound may cause a 
man to acquire such a constitution. Amongst physical 
states, hypotensives are candidates for depression; tubercu- 
losis is particularly important. 

Re MacCurdy's case, the factor of alcoholism was men- 
tioned. The importance of alcoholism, Lepine has particu- 
larly stressed. He particularly emphasizes the number of 
men who have taken to drink to get over their emotions and 
to forget. Visual hallucinations, angry excitability, sudden 
persecutory ideas, nocturnal occurrence of the symptoms, 
flushing of the face, suggest alcoholism. Some of the cases 
of encephalitis which are supposed to be due to some un- 
known bacterium, may really be alcoholic in origin. A third 
of Lepine's cases were alcoholic; perhaps two-thirds really 
alcoholic if one took into account the factor of sensitization. 



460 shell-shock: nature and causes 



Bombardment from airplanes: Fear; suicidal 
thoughts; oniric delirium (" moving picture in the 
head.") 



Case 333. (Hoven, May, 191 7.) 

A soldier (born at seven months, somewhat feebleminded, 
given to depression, early victim of convulsions, talking only 
at five years, with a history of once leaving his father's house 
with suicidal ideas after being scolded, already invalided in 
peace times) on enlistment remained with the regiment but 
a few days and was then sent to a workers' company of 
blacksmiths. 

Toward the end of February, 191 6, his cantonment was 
bombarded by an airplane escadrille. The patient was much 
frightened, ran away and hid in a ditch, felt sick, stopped 
eating, wanted to kill himself and had to be evacuated to 
Calais and then to Chateaugiron. 

He was there found to be well oriented, but depressed and 
bewildered. There was an emotional tachycardia. At night 
he would fall into a delirium like the oniric delirium of Regis, 
always dreaming of the same bombardment scene, saying it 
was like a moving picture in his head. The delirium affected 
him so that he actually tried to make away with himself. 

The dream delirium did not last long but recurred several 
times on very slight emotional occasions. It was possible to 
excite his hallucinatory dreams experimentally by showing 
him battle pictures. 

Some cases of such delirium develop, according to Hoven, 
after moving picture shows of battle scenes. 

Re oniric delirium, Chavigny states that mental confusion 
and oniric delirium are the two forms of mental disorder that 
come most frequently after explosions. He believes that at 
least 95 per cent of these cases are rapidly curable; and, in 
fact, found amongst 60 cases observed in his army service 
that only two were so severe as to require being sent to the 
interior: all the others were cured in six days at the outside. 
These cases, according to Chavigny, ought to be treated in 



shell-shock: nature and causes 461 

special wards at the front (bed, quiet, purgation, baths). 
Chavigny prearranges slight emotional shock for these cases 
by talking with them about their families. Their apparent 
apathy vanishes in a trice. 

Regis, who has named the state " oniric delirium," states 
that the condition never lasts more than a fortnight, is 
caused by emotional shock, and occurs in all cases with 
mental disorder following battle; but similar hallucinatory 
conditions have begun to appear also amongst alcoholics, 
in garrison or at home. There is emotional constitution in 
most of these cases. There is not so much evidence of 
heredity. Out of 50 of Regis' cases, 22 had been wounded, 
and 28 not. Regis states that the psychoses are rather more 
apt to affect men in the reserve, and are severest in officers. 
These cases should not be committed to institutions, but 
ought to be treated in special military psychiatric wards con- 
taining separate rooms. Very fine-spun diagnosis may be 
necessary now and again on account of the occurrence of 
infectious deliria and phenomena of the banal psychoses that 
may closely resemble oniric deliria. 



462 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock ; emotion (best friend mangled) : Stupor 
with amnesia. 



Case 334. (Gaupp, March, 1915.) 

A soldier, 23 (in civil life a turner, of Polish descent, and of 
a somewhat nervous and easily excitable disposition), early 
in August went from Strassburg into the Vosges and Lorraine. 
August 26 a number of shells exploded near him. The troop 
was excited and took refuge in a cellar. His best friend was 
torn to pieces by a shell. When the body was removed, the 
man felt sick and lost consciousness, He arrived at the clinic 
in Tubingen in a stuporous condition, by hospital train, 
August 31, 1914. He walked weakly to his bed, supported 
by two men, and lay in the bed, apathetic and reacting to 
questions only with a stare. Things put in his mouth were 
swallowed. He remained motionless. 

Next evening he answered a low Yes to a nurse's question 
about eating. A little afterwards, he said he supposed he 
was a prisoner in the enemy's country. A while later he got 
properly oriented but still did not know how he had come. 
September 2, however, he was much clearer and said he had 
awakened out of a long dream. There was a complete 
amnesia, however, from the moment when he went to help 
remove the torn body of his friend up to September 1. Mem- 
ories became clearer for the period before the shell explosion. 
The patient became very lively, talking vividly of war 
experiences, imitating the hiss of shells with an expression of 
intense anxiety, getting accustomed to the battle scenes, 
saying that he was now seeing everything again as if real. He 
remained anxious for some days, complaining of weight on 
his chest and of feelings of inner restlessness and tension. 

Amnesia for the period August 26 to September 1 re- 
mained; all that he could say was that he had been thrown 
sidewise for some distance by the air pressure of the shell. 

From September 6 onwards, he grew calmer but he was 
still very labile, given to lively imaginings and emotion. By 
mid September he could be discharged for garrison duty. 



SHELL-SHOCK: NATURE AND CAUSES 463 



Emotional shock 


; shooting 


a comrade 


: Horror, 


sweat, stammer, 


recurrent 


nightmare. 


Improve- 


ment on "tracing back." Brief recrudescence on 


death of child. 









Case 335. (Rows, April, 1916.) 

A man after a charge was placed on outpost duty. It was 
dark, and he was in a state of considerable tension. He heard 
a noise which he thought came from somewhere in front of 
him. Suddenly the space around him was illuminated by a 
flare of light, and he saw a man crawling over the bank. 
Without challenging, he fired and killed the man. Next 
morning, he found to his horror that he had killed a wounded 
Englishman, who had advanced beyond his comrades and 
was crawling back. 

A physical expression of horror, together with an intense 
sweating and a very marked stammer, persisted for months. 
At the same time, he was tormented with a fearful nightmare, 
and in his sleep he was heard to say, "It was an accidental 
shot, sir; yes, Major, it was not my fault." In the day time, 
also, his attention was concentrated on the memory of the 
incident, so that "I cannot forget it no matter how I sky- 
lark.' ' Carrying his story back to this trying time led to 
his recounting his terrible secret, and a marked improvement 
followed. The physical signs of the intense emotion grad- 
ually disappeared. The vividness of the dreams dimin- 
ished, and his attention was less concentrated on the one 
subject. It is interesting to note that the production of a 
marked emotional state by the death of one of his children 
led to a recrudescence of his former symptoms : an expression 
of "horror and the stammer." But they disappeared again 
in a short time. 



464 SHELL-SHOCK: NATURE AND CAUSES 



Emotional shock : Phobias. 



Case 336. (Bennati, October, 1916.) 

An Italian corporal in the infantry, a robust man of a well- 
to-do family, took a good deal of pleasure in the war life. 
One day a comrade was injured by a missile of some sort, and 
died almost immediately. This comrade, after being hurt, 
had thrown himself against the corporal, who was asleep at 
the time. He woke up sharply and immediately felt sick. 
His status was one of great terror, lacrimation, lack of 
spontaneity, and insomnia. He would wake up from sleep 
and start from a terrible dream. He had a number of phobias 
and was especially interested in other persons who had the 
same sort of mental state as himself. He was in a state 
noted by Bennati as one of "emotional anaphylaxis" to 
various events around him. There was a horizontal nystag- 
mus, the Mannkopf sign was positive (87-72), Thomayer 
90-114, Erben 114-90. There was a slight tendency to 
dizziness when the Erben movements were made. 



shell-shock: nature and causes 465 



Shell-shock; fright: loss of consciousness next day : 
Generalized tremors; " somebody above with a 
mallet." 



Case 337. (Wiltshire, June, 1916.) 

A sapper of 19, with a nervous mother, had had an attack 
two years before his war neurosis, of a somewhat similar 
nature. This former attack had been caused by overwork; 
there had been no accident or fright, but the man had been 
unable to work for five months. 

At the front, he had been well up to ten days before obser- 
vation. In a dugout a shell had pitched on top of the bank, 
followed by another shell bursting in front. There was a 
slight falling in of the dugout but no special damage. 

The patient carried on that night but reported sick next 
morning, feeling queer and shaking slightly above the waist. 
He remembered getting half-way down the road to see the 
M. O., but nothing more until he came to in the dressing 
station (perhaps 2| hours later). After two days in hospital, 
he was transferred to a convalescent camp, and then admitted 
to another hospital. He complained of twitching and slight 
frontal headache ; funny feelings at night prevented his going 
to sleep. Thus: "A man was over my head with a mallet, 
going to hit me," There was a dream of " somebody above 
me all the time." Both arms, head, and tongue were in a 
state of constant tremor, and there were jerky movements of 
the legs. There was some spasm of the right leg. Both legs 
went into violent tremor on examination, and during examina- 
tion there was free perspiration. 

Re tremors, all sorts of tremors of unknown nature are 
apt to get the designation hysterical. Meige believes that 
the Shell-shock tremors, which are apt to be very persistent, 
are very possibly due to changes in the nervous system. 
Ballet has noted how the tremors, as in the above case, 
are often associated with expressions of fear. Now and then 
there is an obsessive disorder dubbed tremophobia by Meige, 
which produces a vicious circle. Tremors lead to obsessions, 






466 SHELL-SHOCK: NATURE AND CAUSES 

and the obsessions in turn exaggerate the tremors. These 
Shell-shock tremors are apparently not related to (though 
they may need differential diagnosis from) such conditions 
as paralysis agitans, multiple sclerosis, hyperthyroidism, cere- 
bellar disease, neurosyphilis, and alcoholic or other intoxica- 
tion. 

Roussy and Lhermitte distinguish the tremors into (a) 
atypical ones; that is, disorderly, irregular movements seem- 
ingly determined by the subjects caprice; and (b) typical 
tremors, such as those found in the well-known nervous 
diseases and presumably imitated in hysteria from these well- 
known diseases. Generalized atypical tremors are, as a rule, 
combined with a variety of other Shell-shock symptoms, and 
often exhibit a sort of mimicry of fear. 



shell-shock: nature and causes 



4 T 



Shell-shock; burial-work: Amnesia. Shell whis- 
tling conditions idea of something nasty. 



Case 338. (Wiltshire, June, 191 6.) 

A private, 19, in the R. A. M. C, was sent in with a field 
ambulance note as follows: 

" Private was close to a shell which burst 

among a company standing in the road, killing 20 and 
wounding 20 others. He worked well in assisting the 
wounded, and then proceeded to clear up the fragments 
of the killed. Whilst doing this, he suddenly lost his 
mental balance and has been in his present state nearly 
24 hours. He has been given bromides." 

An M. O. attached to the same ambulance wrote: 
"This man is suffering from mental shock caused by 
having to clear away the remains of a number of men 
killed by a shell. He does not recognize his friends, 
and at frequent intervals has periods of terror, exclaim- 
ing, 'Cover it up.' He is sleepless (without drugs); 
he takes food badly. He is possibly suicidal or may 
become so." 

According to the patient himself, he had been quite well 
for four months at the front. He was on the La Bassee Road 
with the troops after a day or two of heavy work under shell 
fire. "And I remember the flash of some shot and a shell 
burst I think, and I can't remember anything more. I awoke 
in the morning, in the train " (48 hours later). "I can only 
remember men calling out." He complained of a feeling in 
the head, as if expecting something. "Something seems to 
be coming, — as if something was going to happen, — some- 
thing nasty, whenever I hear anything like the whistling of a 
shell coming towards me." This patient was without tremor 
and was physically normal. So far as the patient's own 
story went, the case might well be regarded as one due to 
physical concussion, but the notes of the medical officers give 
evidence of a psychic element. 



/ 



468 shell-shock: nature and causes 



Depression with suicidal thoughts after witnessing 
death of comrade. 



Case 339. (Steiner, October, 191 5.) 

A farmer, 52, volunteered and was put in charge of a 
drinking-water still. He had never been ill nor was there 
any nervous or mental disease in his family. From the end 
of August he was frequently under shell fire, but the only 
effect thereof was a somewhat poorer sleep than normal. 

December 14, 1914, a young comrade, a volunteer, wanted 
to clean his dirty kettle at the drinking-water still. The 
farmer later described this volunteer as a young fellow "like 
milk and blood " (as we might say, "like peaches and cream ") 
and as the handsomest young man he had ever seen in the 
war. The rules forbade such use of the still, and young 
11 milk-and-blood " was told to go down to the brook, and 
then come back and get the distilled water. The young man 
complied, but while at the brook he was shot and killed in 
full sight of the farmer. 

The farmer grew much excited and trembled all over. 
Thereafter he could not eat or sleep; he reproached himself, 
although he knew he had acted quite correctly; wished he 
had been in the place of this comrade; and had suicidal 
thoughts. He was deeply depressed, wept easily, and showed 
manual tremor. Steiner terms the farmer's account of the 
person of the deceased "reactive idealization." After a 
week there was considerable improvement. B. was sent back 
to work, which he felt would be beneficial. He was put in 
less dangerous surroundings, and this also had a good effect. 



SHELL-SHOCK: NATURE AND CAUSES 469 



Marching and battles : Neurasthenia? 



Case 340. (Bonhoeffer, January, 191 5.) 

A subaltern had been treated before the war for nervous- 
ness, dizziness, and " mattigkeit ' ' (convulsions in infancy), 
but proved himself a good soldier, having gotten his rank after 
the first period of practice. 

He was in three battles in Belgium, but on the march one 
day suddenly had a spell of weakness and is said to have had 
convulsions. There was, however, no biting of the tongue, 
and no enuresis. After a week in the field hospital, he was 
sent back to Berlin where he had some somatic feelings of 
anxiety without subjective disturbance or any disorders of 
consciousness except a certain amount of inhibition; he was 
sleepless and hypersensitive, cried easily, and was appre- 
hensive on being touched; he winked violently on examina- 
tion of his eyes, and while being tested for reflexes made violent 
contractions of a semi-voluntary nature. 

After four days in bed, which was a prescription hard to 
carry out at first on account of the anxiety sensations, these 
sensations disappeared, and at the same time the fears. 
Weight began to increase; memories returned, except that 
even upon recovery he could not remember that he had ever 
had any true subjective feelings of fear. He was discharged 
19 days later, desirous of going back into the field. 

The peculiar absence of subjective feelings of fear in this 
case is something like what Awtokratow reported from the 
Russo-Japanese War, terming them neurasthenic psychoses. 

Re neurasthenia, Babinski believes that, by means of his 
logical dismembering of the old hysteria concept, he has 
shown that the exhaustion phenomena at the bottom of 
neurasthenia are precisely these that cannot be cured by 
suggestion. There are numerous cases in which hysteria and 
neurasthenia are combined. From these combined cases, 
suggestion causes the hysterical or pithiatic symptoms to be 
removed. 



470 SHELL-SHOCK: NATURE AND CAUSES 



/ 



English schoolmaster's account of his war dreams. 



Case 341. (Mott, February, 1918.) 

A sergeant, who had been a schoolmaster, was asked to 
write down his dreams by Captain W. Brown, who had some- 
times charge of Mott's cases at the Maudsley Hospital. 
The first dream was as follows : 

"I appeared to be resting on the roadside when a 
woman (unknown) called me to see her husband's 
(a comrade) body which was about to be buried. I 
went to a field in which was a pit, and near the edge 
four or five dead bodies. In a hand-cart nearby was 
a legless body, the head of which was hidden from sight 
by a slab of stone. [He had seen a legless body, which 
was covered with a mackintosh sheet, which he re- 
moved.] On moving the stone I found the body alive, 
and the head spoke to me, imploring me to see that it 
was not buried. Burial party arrived, and I was my- 
self about to be buried with legless body when I awoke." 
The second dream was as follows: 

" After spending an evening with a brother (dead 11 
years ago) I was making my way home when a violent 
storm compelled me to take shelter in a kind of culvert, 
which later turned into a quarry, situated between two 
houses. Men were doing blasting operations in the 
quarry, and whilst watching them I saw great upheavals 
of rock, and eventually the building all around collapsed 
(explosion of a mine) . Amongst the debris were several 
mutilated bodies, the most prominent of which was 
legless. I tried to proceed to the body, but found that 
I was myself pinned down by masonry which had fallen 
on top of me. As I struggled to get free the whole 
scene appeared to change to a huge fire, everything 
being enveloped in flames, and through the flames I 
could still see the legless body which now bore the head 
of my wife, who was calling for me. I was struggling 
to get free when my mother seemed to be coming to my 
assistance, and I awoke to find the nurses and orderlies 
standing over me." 
It appears that the patient had been shouting in his sleep, 
beginning in a low voice and gradually becoming louder until 
at last he was shrieking. The legless body occurred in all 



SHELL-SHOCK: NATURE AND CAUSES 47 1 

his dreams; the sight of this had evidently produced a pro- 
found emotional shock. He had worried a great deal about 
his wife, who was much younger than himself, so that we have 
this incongruous association of the legless body and the head 
of his wife calling him; finally, what more natural than the 
mother to come to his help. The emotional complex is not 
incongruous in this dream, for fear is linked up with the 
tender emotion. 

Re war dreams, see remarks under Case 333 concerning 
oniric delirium. Roussy and Lhermitte say that emotion 
and concussion are the causal factors; but in a case like 341 
we have persistent war dreams of the same general nature. 
Such a case as Mott's would not be regarded as one of oniric 
delirium, for the patient is not living throughout the day in 
a dream, but merely has certain set dreams. The true 
oniric delirium cases may lead to fugues of medicolegal im- 
portance. Mott's conception is that the terrifying experi- 
ences that come to light in the dreams are repressed by the 
conscious activity of the mind in the waking state. For this 
process, the phrase psychic trauma might be used. Rows 
speaks of a prolongation of mental disorder through memo- 
ries which get revived in dreams. The memories of past 
and recent events pile up on one another. Elliot Smith 
remarks on the number of cases in which the dreams show a 
coalescence and blending of episodes alien to the war. Re 
such combinations, see Case 342 of Rows, below. 



472 shell-shock: nature and causes 



Trench experience: War dreams, shifting to sex 
dreams. Recovery on giving the patient an insight 
into the nature of his dreams. 



Case 342. (Rows, April, 1916.) 

A patient broke out of a hospital after being refused 
permission to leave the grounds. He grew much depressed 
and said he had been disgraced and would commit suicide 
rather than bring disgrace on his family. Investigation into 
this emotional outburst showed that his father had deserted 
the family, that he had gotten into prison, and "tainted me." 
The patient was worried also about an idea of loss of sex 
power, gathered from a book by a quack doctor, read years 
ago. It appeared also that this doctor had advertised a 
special bread and special medicine which would preserve the 
nervous system, and that for years the patient had fed him- 
self and his family with the bread and medicine. When the 
true state of affairs was shown to the patient, his restlessness 
at night disappeared. The mental condition of this man 
in fact became practically normal, and the marked tic of 
facial muscles and the general tremulousness of the man 
disappeared. 

It is of note that this man's dreams began with a terrible 
incident in the trenches and then shifted to sex acts. He 
woke to find the clothes disturbed. 

This is an example of hallucinations dispelled by trac- 
ing them to their source, and giving the patient a clear 
insight into their nature. 

According to Ballet and de Fursac, after the acute phase 
of stupor and excitement with hallucinations and delirium 
passes, the patient remains a depressed and psychasthenic 
subject. In this psychasthenia we find inhibitory phenom- 
ena, hyperemotionalism, and over-imagination. Amongst 
the inhibitory phenomena are many of the hysterical effects. 
The hyperemotionalism yields anxiety, worry, tremors, res- 
piratory and vasomotor disorder, dizziness, convulsions. 
The third main disorder of the psychasthenic state into 



SHELL-SHOCK: NATURE AND CAUSES 473 

which the patient relapses is over-imagination, whereunder 
we find bad dreams (bombardments, drum-beating, corpses, 
attacks), somnambulistic hallucinatory episodes. It is these 
hyperemotional and hyperfantastic features that distinguish 
the Shell-shock syndrome from ordinary psychasthenic states. 
Re the sex element in this case, see remarks under pre- 
ceding case (341) and also Lepine on the sex factor (Case 
332). Rows believes that those cases which do not recover 
after a short period of rest and quiet in hospital are cases in 
which there is some emotional state based upon the constant 
intrusion of the memory of some past event. The physical 
expression of the emotion of fear or terror may persist for a 
long time quite unchanged and be proved to be due to this 
old factor. 



474 SHELL-SHOCK: NATURE AND CAUSES 



Emotional shock: Recurrent dreams of war and 
peace incidents. Recovery followed tracing the 
dreams to their origin. 



Case 343. (Rows, April, 1916.) 

A soldier and a comrade were carrying a pail of water to 
the trenches. It was very cold and they set down the pail 
in order to warm their hands. The comrade placed his hand 
against the man's cheek and said, "That hand is cold." At 
that moment he was shot dead. 

This incident was involved not only in dreams at night, but 
in the daytime too, if he were quiet and closed his eyes, he 
could feel the cold hand against his face. 

He was troubled at the same time by another dream, in 
which he ran down a narrow lane at the bottom of which there 
was a well. He dipped his hands into the water, but on with- 
drawing them, he was horrified to find they were covered 
with blood. This dream was connected with a love affair, 
in which a good friend interfered and angered him so much 
that he attacked him when next they met. He left him on 
the ground so injured that it was necessary to take him to a 
hospital. The patient became anxious as to what the result 
might be and left the district. He traveled, but never heard 
whether his victim had died. 

When these two dreams were traced back to their origin 
they disappeared : the patient made a rapid recovery and was 
able afterwards to bear a severe trial satisfactorily. 

See remarks under Case 342. 



shell-shock: nature and causes 475 



War dreams, including hunger and thirst. 



Case 344. (Mott, February, 1918.) 

{Recorded Dream of a Second Lieutenant.) 

"During the five days spent in the village of Roeux I was 
continually under our own shell fire and also continually 
liable to be discovered by the enemy, who was also occupying 
the village. Each night I attempted to get through his lines 
without being observed, but failed. On the fourth day my 
sergeant was killed at my side by a shell. On the fifth day 
I was rescued by our troops while I was unconscious. During 
this time I had had nothing to drink or eat, with the exception 
of about a pint of water. 

" At the present time I am subject to dreams in which I hear 
these shells bursting and whistling through the air. I also 
continually see my sergeant, both alive and dead, and also 
my attempts to return are vividly pictured. I sometimes 
have in my dreams that feeling of intense hunger and thirst 
which I had in the village. When I awaken I feel as though 
all strength had left me and am in a cold sweat. 

" For a time after awaking I fail to realize where I am and 
the surroundings take on the form of the ruins in which I 
remained hidden for so long. 

" Sometimes I do not think that I thoroughly awaken, as I 
seem to doze off, and there are the conflicting ideas that I am 
in the hospital, and again that I am in France. 

" During the day, if I sit doing nothing in particular and I 
find myself dozing, my mind seems to immediately begin to 
fly back to France. 

11 A dream that keeps on coming up in my mind is one that 
brings back a motor accident I had about six years ago, which 
gave me a severe nervous shock. I had, of course, entirely 
forgotten about it, except when in a motor, when I always 
thought of it. 

" Of the fifth day I have absolutely no recollections." 

This is the one instance in which a man has dreamt the 
experience of hunger and thirst in addition to battle ex- 
perience. 



476 SHELL-SHOCK: NATURE AND CAUSES 



Olfactory dreams : Hysterical vomiting. 



Case 345. (Wiltshire, June, 191 6.) 

A lieutenant in the infantry (mother, of a nervous dis- 
position) had been at the front for 3^ months when he started 
vomiting everything he ate. 

He was transferred a fortnight later to a base hospital as 
"gastritis." Physical examination proved negative, but the 
man complained of his nerves. He slept badly owing to 
trench-life dreams, from which he would wake in a sweat. 
He was quite unwilling to refer to these dreams. 

In point of fact he had had to supervise the burial of many 
decomposing bodies, after which he had been haunted "by 
that awful smell of the dead." Then developed states of 
abstraction, in which he went over and over the burying 
experience. He cried by himself. 

It seems that the vomiting was secondary to hysterical 
hallucinations. 

Re affections of smell and taste, Roussy and Lhermitte 
remark that they are rare following shock or trauma in war. 
Medical suggestion may produce a hemiageusia or a hemi- 
anosmia. Mott's case above (344) showed unusual dreams 
with hunger and thirst. For another olfactory case, see 
Case 510 (Rivers) in the Treatment Section of the book, a 
case in which Rivers was able to find no redeeming feature 
upon which to ground his re-educative suggestions. 

Re vomiting, Roussy and Lhermitte state that this rela- 
tively common condition is diagnosticated readily enough 
but that pyloric ulcer and other organic causes must be 
eliminated. They remark that there is no tendency to spon- 
taneous cure of neuropathic vomiting, and commend strict 
dietetic regime and psychotherapy. They ally the condi- 
tion in its nature and genesis with so-called false or hysteri- 
cal incontinence of urine in soldiers. Wiltshire's case early 
received the diagnosis "gastritis." Itfis remarkable how 
little emaciation need follow such vomiting. 



shell-shock: nature and causes 477 



L 



Shell-shock : Amnesia ; dreams of falling. POST- 
ONIRIC suggestion — surprise produced fear of 
falling. 



Case 346. (Duprat, October, 191 7.) 

A man was subjected to shell-shock August 11, 1916, at the 
Somme. He lost consciousness for five hours and was picked 
up stuporous with verbal amnesia, which soon passed leaving 
only a difficulty in getting the right word promptly. He 
began to have frightful dreams of falling into a hole and of 
exertions to avoid falling, whereupon he would awake with 
a feeling of anxiety that would last some time. Treatment 
caused the dreams to disappear. 

There remained, however, a powerful post-oniric suggestion. 
Any slight surprise would cause the fear of falling to reappear. 
There was a sort of derived phobia, against any military act 
that would need to be performed upon sudden order. He 
developed a blind anger against any commanding officer who 
gave a brusque order. After the crisis of anger he would fall 
into tears and a feeling of profound depression coupled with 
precordial anxiety. There was also a chronic aortitis physi- 
cally determined. The man himself had a vague idea of the 
relationship of his fear of surprise to the old nightmares. 

Re persistence of fear and its relationship to nightmares, 
see remarks under Case 342 (Rows). 



478 shell-shock: nature and causes 



Four months' SERVICE IN THE REAR: Depres- 
sion; war HALLUCINATIONS (not based upon 
actual experiences) ; psychasthenic symptoms. 



Case 347. (Gerver, 1915.) 

A Russian lieutenant, 32, arrived at the front in November, 
1 9 14, but never served on the front line, or had occasion to 
visit the line or the trenches. Toward the close of February, 
mental symptoms appeared, which caused the man's evacua- 
tion to the interior. 

He was a tall, well-built, well-nourished man, who was 
physically normal except for sharp twitching movements 
of the tongue, eyelids, and face; tremors of extended hands, 
occasionally spreading to the whole body; well-defined der- 
matographia (in places, stereodermatographia) ; exaggerated 
tendon reflexes ; tenderness of skull and spine ; hyperesthesia 
of chest; pulse 120. 

Mentally, the patient was markedly depressed, irritable, 
at times lacrimose. His complaints were of a psychasthenic 
tinge. He feared incurable disease. He feared to go to the 
front, and was terrified at what he might do there. He feared 
crowds of soldiers; he was afraid of forests and mountains; 
the Germans were going to break through and capture him; 
shells were about to burst over his head. He was also dis- 
turbed about his family, regarding his wife and son as helpless, 
sometimes even as dead. Suicidal thoughts at times. 

At night, though he had never been at the front, he had 
hallucinations of shots and the voices of soldiers, as well as 
those of his wife and son. He smelt an unpleasant corpse- 
like odor. He was unable to distinguish these hallucinations 
in any respect from reality. He complained of general 
weakness, headaches, palpitation of the heart, vertigo, and 
insomnia, and of a variety of pains. 

He was non-alcoholic and non-syphilitic, and had been in 
perfect health before the war. 

Re war hallucinations with service back of the line, com- 
pare remarks of Regis (see under Case 333). 






shell-shock: nature and causes 479 



A case of hysterical astasia-abasia develops "big 
belly" ("catiemophrenosis"), perhaps by hetero- 
suggestion from a ward neighbor. 



Case 348. (Roussy, Boisseau and Cornil, May, 191 7.) 
A farmer, 22, of the foot chasseurs, who had been in various 
hospitals with a variety of diseases before his injury, was 
evacuated June 2, 1916, for "contusion of back," to the tem- 
porary hospital at Bussant, from which he was evacuated to 
Pontarlier for " contusion of back and cerebellar shock " and 
thence, July 21, to Besancon for "internal contusion and cere- 
bellar shock"; thence to four other hospitals from July 31 to 
February 17, 1917; finally to the Hospital at Veilpicard with 
"functional disorders, paraplegia, trepidant astasia-abasia." 
It seems that he had lost consciousness for fifteen days and 
had thereafter been paraplegic with retention of urine. The 
abdomen had then increased in size in such wise as to be 
termed a nervous pregnancy, grossesse nerveuse. The evolution 
of this pseudotympanites was probably related to the presence 
of the same so-called "big belly " of a patient who had been 
in a neighboring bed from May, 191 6, onwards. The feet were 
in equine position with toes flexed, suggestive in all ways of 
hysterical paraplegia. The abdomen looked like that of a 
woman six months pregnant and measured 78 centimeters in 
a plane passing through the anterosuperior iliac spines and 
the] umbilicus. The abdomen was hard, tense, swollen, and 
on palpation, gave out a low, tympanic note. When the 
diaphragm was mobilized progressively and slowly, the tym- 
panites could be made to disappear. Slow pressure on the 
abdomen with flat hands effaced the swelling for the time 
being; but upon release of the hands the abdomen would swell 
up again as before. Pressure on the abdomen produced a 
contracture of the recti. Forced flexion of thighs on pelvis 
(as suggested by Denechau and Matrais) also caused the 
swelling to go down. Faradization of the phrenic nerves in 
the neck caused respiratory movements with a slight diminu- 
tion in the volume of the abdomen. There was an obstinate 



480 SHELL-SHOCK: NATURE AND CAUSES 

constipation requiring daily lavage. Respiratory movements 
were short and rapid and of the thoracic type. Abdominal 
compression caused the respiration to assume almost a normal 
rhythm. X-ray examination of the abdomen, after 50 grams 
of bismuth carbonate had been taken in three spaced doses 
the evening before, showed the intestine to be distended by 
gas in such wise that the lower border of the liver became 
clearly visible, as after insufflation of the stomach. The bis- 
muth was found in the large intestine. The splenic angle 
filled with bismuth was low. On compression the splenic 
angle was raised with the diaphragm. 

The main features of this disease are the large abdomen, 
simulating what has hitherto been found chiefly in females 
under the name of j nervous pregnancy, but also suggesting a 
tuberculous peritonitis (one patient was actually evacuated 
to a hospital for tuberculosis with this disease) ; gastrointes- 
tinal disorder with aerophagy, aerocoly, and obstinate con- 
stipation (one case also showed almost daily vomiting) . The 
genesis of the condition appears to be a contracture of the 
diaphragm in a low position of forced inspiration. The con- 
dition may be termed a diaphragmatic neurosis. 

Psychotherapy was applied, the patient was requested to 
walk, and the movements made in walking required such an 
intense respiration that the diaphragm was forced to function, 
whereupon the "big belly" disappeared. The digestive dis- 
orders then rapidly disappeared. These authors suggest the 
name of catiemophrenosis. 



SHELL-SHOCK: NATURE AND CAUSES 48 1 



War stress ; collapse going over the top : Neuras- 
thenia (hereditary taint ; alcoholism). 



Case 349. (Jolly, January, 191 6.) 

A German soldier, 35, of a nervous make-up (his mother 
was nervous, and he had been nervous and tremulous and 
easily excitable, and alcoholic to the extent of at least 5 
glasses of beer every night), was called to the colors in Sep- 
tember, 1914. He got through his training well; in May, 
1 91 5, was on very strenuous duty in a very exposed position, 
had frequently to stand up under heavy shelling, had a num- 
ber of frightful experiences, was surrounded by corpses and 
mutilated bodies, and frequently took part in storming attacks. 
His nervousness came to a head with some suddenness; just 
as he was about to "go over the top," he had no strength for 
the effort and collapsed. Thereafter he could no longer 
stand shelling, could not speak, and was inattentive to sur- 
roundings. When he was examined by a physician he fell 
asleep in his presence, although sleep had latterly been al- 
most impossible on account of the shelling. He was im- 
mediately put on the hospital train and taken to the reserve 
hospital in Nuremberg, where he presented an appearance of 
extreme exhaustion, wept, seemed much fatigued, and trem- 
bled all over whenever he started to do anything. He was 
very easily excited and especially sensitive to noise. There 
was a fine tremor of the whole body and especially of the 
head; the knee-jerks were increased; there was a moderate 
vasomotor reddening of the skin after stroking; his tongue 
was heavily coated ; but there was no other evidence of inter- 
nal disorder. His pulse was strong and not rapid. 

The patient got well gradually, complained at first of bad 
dreams, and was given to weeping. The tremors slowly 
improved. The patient grew better in a hospital at home. 

As to the diagnosis of this case, Jolly regards it as one of 
nervous exhaustion. The remarkable feature is the tardiness 
with which the symptoms developed under the stress of war. 
Such a patient would probably never develop a neuras- 



482 SHELL-SHOCK: NATURE AND CAUSES 

thenia under normal peace conditions. After recovery these 
patients may be sent back for garrison duty or for other 
work not directly connected with the firing line. As for the 
tendency to desire a pension, this wish, according to Jolly, 
must be strenuously opposed, both in the interest of the 
state and that of the patient. If there is no will to get well, 
some of these patients are found vibrating from garrison 
service to furlough and to hospital. 

The above case is one of the simplest observed ; yet there 
is evidence both of hereditary taint and of alcoholism. Ac- 
cording to Jolly, the majority of the severe exhaustion states 
of a neurasthenic nature have been, in his experience, dis- 
tinctly nervous before the war, and frequently show heredi- 
tary taint as well. 

Re neurasthenia, see views of Babinski relative to differ- 
entiation from hysteria (under Case 340). 



SHELL-SHOCK: NATURE AND CAUSES 483 



Series of battles : Sudden mania followed by con- 
fusion with fixation of mind upon war experiences, 
possibly hallucinatory; general analgesia. 



Case 350. (Gerver, 1915.) 

A Russian private, looking much older than his years (35), 
had been in a number of battles without mental disorder. 
Where he was posted, however, there was a heavy artillery 
fire in the last of the battles. Suddenly the man became 
excited and leaped upon his comrades' shoulders crying, 
"The devil is here! This is hell and murder, and here are the 
devil's imps! " The commanding officer accordingly ordered 
him to the rear. His regiment had suffered severe losses in 
a succession of attacks upon a certain strategic height. 

Upon evacuation to the field hospital and thence to the 
interior, his excitement did not lessen. He went about with 
a lost look, trembling, talking a great deal and gesticulating. 
His talk was incoherent and pointless. After every few 
phrases, he would repeat, " Don't ride there! That's hell! 
Murder is being done. Devils and unholy powers are beat- 
ing and killing people." As he said this, he would tremble, 
and hands and feet would stiffen with a suggestion of cata- 
lepsy. There was general anesthesia to pain; no response 
was made to deep pin-pricks. The pupils were dilated and 
failed to react, either to light or to pain. The tendon reflexes 
were exaggerated. No contraction of visual fields. The man 
was disoriented for time and place and much confused. No 
paralysis. No wound or contusion. 

Re analgesia, we may only say that hysterical anesthesia 
appears in a variety of forms; sometimes (a) in the form of 
a classical stigma of hemi-anesthesia ; (b) in a segmentary 
form; again (c) in isolated patches; (d) in a very rough 
way approximating the peripheral nerve distributions. Ba- 
binski gives an unpublished note by Lasegue, in which he 
states that hysterical patients not enlightened by the doc- 
tor's investigations do not make mention of anesthesia. But 
in case 350 a psychotic factor may have entered. 



484 SHELL-SHOCK: NATURE AND CAUSES 



Ten months of military service (several battles) 
without reaction ; then, hot machine gun battle : 
Mania with disorientation and war hallucinations. 



Case 351. (Gerver, 1915.) 

A Russian private, 24, in a scout company, entered the 
war on mobilization and took part in several battles without 
reaction. May 11, 191 5, he was sent with the scout party 
into a hot encounter, hand to hand with machine-guns. 
After the battle, the man began to yell incoherent phrases at 
the men around him, started to climb over the top, and shot 
off his gun without permission. He was accordingly sent to 
hospital, where he was under observation for a week, during 
which he had occasional flashes of excitement, jumping out 
of bed and making movements of cutting or shooting, and 
then in a few minutes subsiding into inactivity. 

He was a short but well-built and well-nourished man; 
the pupils responded rather weakly in accommodation ; there 
was a small fibrillar tremor of the face, eyes, and tongue. 
The skin reflexes were diminished and there was a general 
hypalgesia; considerable mechanical overexcitability of mus- 
cles; no other neurological disorders. The mental state was 
one of confusion. Although he was in one of the corps hos- 
pitals, he said he was in a dug-out; the doctors were lieuten- 
ants ; the attendants were privates in his company. Answers 
to questions were irrelevant or incoherent; there were a 
number of delusional expressions. He was to be shot be- 
cause he had not himself shot enough Germans. If he were 
not to be shot, anyhow the soldiers would poison him. 
Rather than this he should be allowed to go into an attack. 
Hejwould take a German fort and the Czar would name him 
a colonel. His regimental commander was saying to him, 
"You will be a hero, you will soon get a company." His 
hallucinations sometimes included the voices of Germans 
saying, in broken Russian, " We will hang you and cut your 
belly open ! " There was considerable amnesia for dates 
and even his last battle. 



SHELL-SHOCK: NATURE AND CAUSES 485 



Numerous attacks and counter attacks in one day : 
Sudden incoherence with disorientation and the 
rapid development of war hallucinations of a scenic 
type. Suggestion of catatonic phenomena. 



Case 352. (Gerver, 1915.) 

A Russian lieutenant, 28 (no mental disease, non-al- 
coholic), was in battle August 14, 1914, on which day his 
company attacked and was itself attacked several times. An 
officer who observed the lieutenant said that he came to him 
and informed him that the Germans must first be burned and 
then fought with. Thereafter the lieutenant began to speak 
loudly and incoherently, sometimes yelling incoherent orders. 
He was accordingly removed from the battle-field to the hos- 
pital back of the line. Upon examination, he was found to 
be of middle height, with dilated pupils, responding weakly 
to light and not at all to accommodation ; twitchings of face, 
eyelids, and tongue, digital tremor, marked dermatographia, 
general analgesia, tendon reflexes somewhat exaggerated, 
cataleptic tendency in feet and hands. 

Mentally, the patient was in a stupor, sitting or standing 
in one place, without initiative ; uncomplaining but occasion- 
ally uttering deep sighs or occasional isolated phrases. He 
answered no questions or only after a long pause. He was 
disoriented for time and place, but gave evidence of delu- 
sions and hallucinations. He thought, for example, that he 
was the chief of staff and had brought with him a squad of 
captured Germans who were standing nearby. Some wanted 
to be fed and let go; others were yelling and saying they 
would burn down the house. Sometimes the patient would 
hear shots and shells bursting, at which he would shudder 
and turn away. Apparently he would see his comrades fall- 
ing under the shrapnel hail. However, he stood his ground 
and commanded the rest of the soldiers to go forward to the 
attack. Now and then he was negativistic, flexing the hands 
upon request to extend them, refusing food and drink. He 
was still apathetic on evacuation to the interior. 



486 shell-shock: nature and causes 



Shell-shock after two days in trenches: Hysteri- 
cal STUPOR seven days. Cure in three weeks, 
barring amnesia for stuporous period. 



Case 353. (Gaupp, March, 1915.) 

F. S., in civil life a wreath-binder in a flower shop, and 
from childhood very nervous and excited, subject to frequent 
nosebleeds and fainting spells (e.g., at sight of blood), en- 
listed at 22, November 3, 1914, as a reservist. January 18 
he went into the field. 

The wreath-binder was only two days in the trenches 
before going unconscious under the whistling and exploding 
shells. Physically uninjured, he was received in reserve 
hospital C in a deep stupor, January 22. He was unre- 
sponsive at first, once however saying, lost in a dream, "When 
will mother come? " His gait was unsteady and he had to 
be led and held. He slept a good deal in the daytime. 

He became somewhat more active mentally, January 24 
(remarking that he had slept well), and made his toilet, but 
he did not yet have bearings and wanted to go to his place of 
business. The next day his condition was similar. Asked 
what troop he was with, he said, "In the flower business.'' 
January 26 he was much better, telling of the army training 
and a little about the war, and wrote a postcard to his par- 
ents. The stupor disappeared after January 27 and the 
patient became mentally normal. Amnesia persisted for the 
time, January 20 to 26. Headaches. February 9 he was 
well, except for the [limited amnesia still persisting. He was 
eventually sent back to garrison duty, cured. 

Re stupor, Grandclaude remarks that stupor is probably 
the most frequent of the mental symptoms of Shell-shock, 
and that it may last from a few moments to a week. During 
the stupor the patient is asthenic, stertorous, and staring. 
Upon recovery from the stupor, a condition of dulness with 
amnesia and disorientation ensues. There may be a third 
phase of a more hyperkinetic character, with hallucinations 
and delusions concerning the war. These stuporous cases 



SHELL-SHOCK: NATURE AND CAUSES 487 

( 

are among the most serious of the conditions found, as some 
of the victims may even suggest dementia praecox from the 
persistence of childishness and silliness. As in Gaupp's case, 
Grandclaude finds that headaches and amnesia persist. Re- 
lapses are frequent on the basis of a kind of sensitization. 

Re amnesia and Shell-shock, Roussy and Lhermitte speak of 
amnesia as ordinarily a phenomenon of confusion. Amongst 
the mental disorders of the Shell-shock psychoses, these 
authors describe a group due to inhibition or diminution of 
mental activity, including the rare narcolepsy, or pathologi- 
cal sleep, and the confusional states proper. Simple con- 
fusion involves slowness in thinking, and amnesia often 
anterograde from the moment of the shock. Simple con- 
fusion ought to be distinguished from so-called " obtusion" 
or torpor, in which there is a disorientation for time and space, 
such as was shown in Mallet's case. Chavigny has described 
an aprosexic form (with "birdlike" movements). • More com- 
mon is the amnestic form of torpor. The amnesia may not 
merely be anterograde from the moment of shock, but may 
extend to a prolonged period prior to the accident. Some- 
times the amnesias are selective, producing phenomena of 
pseudo aphasia. 



488 SHELL-SHOCK: NATURE AND CAUSES 



Amnesia, monosymptomatic. Progressive re- 
covery. 



Case 354. (Mallet, January, 191 7.) 

An infantryman, 36, arrived without information at a 
psychiatric center, March 15, 19 16, looking confused and 
knowing little more than his name, believing himself in a 
distant town. The disorientation lasted to March 21, on 
which day the man recognized the doctor as such, knew that 
he was at a hospital, but felt that he had just left home and 
wife. From this time on, he began to pick up his surround- 
ings, evidently not knowing that there was a war or that he 
was a soldier. He did not recognize one of his own com- 
pany. It was not until March 31 that the first memory of 
the war reappeared, namely, a memory of the call to the 
colors, drums, bells, and crowds. April 11 he recollected 
that he was a soldier and that his wife was in the country, 
where he had left her on the eleventh day of the mobilization. 
In the next few days, memories came back bit by bit. He 
had been at first a little thin and showed a slight fever, 
oliguria, and poor digestion. All these symptoms now 
lapsed, and the man became apparently perfectly well. 

Such states, according to Mallet, are relatively frequent 
in soldiers, both in epilepsy, and in infectious deliria, — 
more than in the deliria of exhaustion. 



SHELL-SHOCK: NATURE AND CAUSES 489 



Aviator shot down : Organic mental symptoms. 



Case 355. (MacCurdy, July, 1917.) 

A Canadian, 20, of normal makeup, in 191 5 lost part of 
his left foot in a railway accident, but, notwithstanding, was 
finally commissioned in the Royal Flying Corps. He en- 
joyed the nine months of English training greatly. In 
France he made several successful nights over the lines, but 
was shot down and crashed to the ground within the British 
lines after two weeks of service. He got black eyes and 
bruises and lost consciousness for about four days, though a 
week later he was still hazy about recent events and was not 
quite sure in what hospital he lay. After another week he 
arrived in a London hospital. 

Here he would not answer questions, but stared at the 
examiner, finally shouting: "I want to get up." He said he 
was in a certain suburb of Toronto, which, however, he in- 
sisted was a part of London not far away. He wanted a 
taxicab to go thither. He pondered, but seemed content 
when told that Rosedale was across the ocean. A super- 
ficial machine gun wound of the hip the patient said must be 
the mark of a hospital in France it was a secret mark, 
meaning that he could return to the line and fight whenever 
he wanted to and that he could use the lavatory whenever 
he wanted to. He sometimes uttered brief phrases after 
questioning. Asked if he dreamed, he looked up cunningly 
and said, e.g., "I down the Boche. I am a live wire." 

Next day it was clear that he had gained a good deal of 
information from the nurses, and the day after he had be- 
come oriented for time and able to recognize the physician, 
though still confused about hospital names and his recent 
movements. The 7 from 100 test he did slowly and made 
several bad unrecognized mistakes. He was over-fatigue- 
able, complained of foggy eyesight, showed haziness and red- 
ness and obscure margins in the optic discs, with the remains 
of one hemorrhage, and presented nystagmus on looking to 
the extreme left. Two weeks later he complained less of his 
memory and said that he was beginning to remember what 






490 SHELL-SHOCK: NATURE AND CAUSES 

had happened during the last day of his fighting; the chase 
by the German airplane and the maneuvers. He worried 
about being sent back to France by a medical board, which 
would not realize that he was incompetent to fly again. The 
left pupil was slightly larger than the right. 

In this case there were no neurotic symptoms and accord- 
ing to MacCurdy the difficulties here are strictly those of 
organic type. 

Re organic cases of traumatic psychosis, Lepine sums up 
the subjective phenomena as follows: There is (a) a cephalea, 
often a feeling of weight, varying at different times of the day ; 
often frontal; often subject to marked alteration on move- 
ment. There may be (b) a number of visual phenomena like 
those mentioned under Case 355, part and parcel of a sort 
of absence, suggesting an epileptoid effect. Sometimes (c) 
there is vertigo, but this is rare. There are also congestive 
attacks. The patients are unable to work, and have strange 
head sensations when they attempt to work. The memory 
disorder is not as a rule markedly accentuated. This am- 
nesia is usually a disordered fixation of current events, but 
there is also a retrograde amnesia. Insomnia and impulsive- 
ness are also found, and more rarely is a depressed and 
melancholy state suggesting that which Case 355 exhibited. 
Lepine has tried to define the traumatic psychoses (not 
neuroses) on the basis of phenomena found in trephined 
cases. He remarks upon the extreme analogy, not to say 
identity, between the late sequelae of trephining and the 
syndrome of commotio cerebri. 



SHELL-SHOCK: NATURE AND CAUSES 49 1 



Daze with relapses ; mutism — following shell fire 
and corpse work. 






Case 356. (Mann, June, 1915.) 

A soldier lost his voice apparently from two factors: shell 
fire and the emotional shock of helping to fill the big common 
graves. The man could never tell for certain (retrograde 
amnesia) whether he went from corpses to shell fire or from 
shell fire to corpses. 

Several weeks of daze followed in which he hardly reacted 
to outward stimuli, but occasionally said "It smells!" 
"Leave me still!" 

He recovered gradually from the daze. But merely hinting 
at his experiences, especially the smells, sufficed to throw 
him into another daze. 

The loss of voice lasted for some time after he had wholly 
stopped lapsing into the dazed states. 

There was some alcohol in the previous history of this 
case, which is the only case among twenty-three Shell-shock 
cases reported by Mann which had a psychiatric disorder of 
any lasting nature due to shell fire. 

Re mutism and the two factors of shell fire and emotion 
spoken of by Mann, compare the views of Babinski to the 
effect that emotion alone is unable to cause such a hysterical 
manifestation as mutism 

Re the corpse work, see remarks under Case 342. 



492 SHELL-SHOCK: NATURE AND CAUSES 



Mine explosion: Mental confusion. Amnesia 
effected through Y. M. C. A. 



Case 357. (Wiltshire, June, 1916.) 

A sapper, 21, was admitted to a base hospital semi-stupor- 
ous, unable to answer questions and mistaking the identity 
of persons about him. At first he slept, but next day found 
he was in hospital. His mind was "all of a blur." He did 
not remember coming to France; " It all seems a mist." He 
felt he was ill and was afraid of becoming insane. There was 
no physical sign of disease except coarse tremor of hands. 

At intervals over a period of about half an hour, helped 
by questions, he was able to get out the following with 
much emotion: 

11 Joe, don't go — Give me my rifle, Joe — Ten killed. 
Poor old Taffy — Dreamed last night — Saw Harry 
Edmands with all his ribs broken — when we had the 
explosion — 5000 bombs or two and a half tons of ex- 
plosives blew up. — Joe — Clay said he would never 
live three weeks, — Glasses blown in. — Taffy killed 
by shell in stomach — S — L — All privates blown 
off him — Just after leaving workshop." 

Between the above statements, the patient might go off 
into short trance states, staring and pointing out of the tent. 

Next day he was found in a condition of cheerful emotion, 
saying that he was ever so much better; an orderly had 
"saved him! " This orderly had taken him to the Y. M. C. 
A. recreation tent, played the piano to him, and made him 
play himself. His whole emotional state suddenly changed 
over. He now had a good memory for everything previous 
to his reaching France, and remembered simply that there 
had been an explosion. He remembered two names that he 
had mentioned, but he could remember nothing about their 
fate in France. He did not know where they were but he 
was not anxious about them. 



shell-shock: nature and causes 493 



Shell-shock: Hallucinations; alternations of per- 
sonality. 



Case 358. (Gaupp, March, 1915.) 

A soldier, 29, a helper in a wholesale house, came to a 
hospital by hospital train, uninjured, directly from the field, 
having become completely deranged under shell fire. He 
arrived at the clinic January 11, 191 5, in deep emotion, 
anxiously excited, and looking tensely and suspiciously at the 
bystanders. He seemed to hear very badly and shouted his 
statements like a deaf person. Led to the sick section, he 
shouted out of the window, "Frenchmen!"; then he went 
willingly to the bath and was put to bed, unresisting. He 
lay in bed on his elbow, listening in the direction of the 
window or the wall, answering loud questions with a quick, 
yelling voice after a pause. He gave his name correctly. 
He seemed to think he was in the trenches and to see hal- 
lucinatory pictures of battle. 

In the examining room he immediately sat down, back 
to the wall, taking the chair at the desk and leaning it against 
the wall. Asked why he did so, he said with a horrified ex- 
pression, "The shells, they are coming over! Whew! they 
are shooting all the time." He ducked, imitating the hissing 
and whistling of the shells. Asked if he had been struck, he 
said, "There are two dead and one's head is off." He de- 
clined to be told where he was, and when he was told that he 
was no longer in the enemy's country, but in Wurttemberg, 
he said, "No, no; they don't come so far. No, the French- 
men don't come so far." He was very easily frightened and 
started at every touch as if wakened from a dream. Some- 
times his whole body would tremble with anxiety. He 
would not allow his pulse to be taken, at first. He would 
suddenly shout, "That's the Krupp now flying by. Now it 
has struck." He cast his eyes along the ceiling as if to follow 
the course of the shell. Asked what he was doing, he said he 
was in the trench on the mountain. 

He was able to tell about his family, his marriage in Berlin, 



494 SHELL-SHOCK: NATURE AND CAUSES 

and his child, and he could tell time by the clock. Then he 
would suddenly shout : ' ' The shells, they are shooting every- 
thing; they are shooting like another earthquake." Gaupp 
stepped up to him, in uniform, and asked if the patient knew 
him. He examined Gaupp suspiciously from top to toe, 
looked at the shoulder-straps, and then quickly cried loudly, 
"Physician." 

At a.nother time he described the shell havoc with evidence 
of extreme anxiety. He would take food only when one 
broke off a piece and ate of it before him. He would not 
drink out of ordinary drinking-glasses but only out of his 
field cup, examining it carefully. He denied he was on patrol 
duty at Soupis. His comrade was merely asleep just now. 
A civilian physician in his long coat was termed by the 
patient "a baker " after careful examination. There seemed 
to be no pause in the man's behavior, which looked abso- 
lutely genuine and dominated by strong emotion. He had 
the look of a man in immediate danger of death, exerting 
himself to escape shell fire. 

This dream-like disorder of consciousness with war de- 
lirium persisted for a number of days. There was no marked 
motor excitement. He would remain for the most part 
quietly in bed, absorbed in his thoughts, watching and listen- 
ing, sometimes looking about in astonishment but not getting 
his bearings. Gradually his emotions declined and he de- 
veloped a certain confidence in the nurse. She was able to 
convince him that he might be in a hospital, although he 
objected that there were no wounded there. (He was in a 
mental section where there were no bandaged men.) All 
the while he was very hard of hearing and shouted loudly in 
speech. For twelve days he could not be convinced that he 
was in Germany. The fact that the Sister was speaking 
German was met promptly by the fact that in France the 
physicians and Sisters spoke German too. 

An extraordinary change came over him January 27 
(sixteen days after admission). He went into the garden, 
apparently deaf and shouting his answers, accompanied by 
Sister Margarethe, whom he always called " Sister Anna" 
and whom he thought came from Lichterfelde. While walk- 



SHELL-SHOCK: NATURE AND CAUSES 495 

ing with the Sister, his condition suddenly disappeared. He 
began to hear; he spoke in a normal tone, in fact, rather low, 
and began to address the Sister by her right name, Mar- 
garethe. He was astonished at the snow in the garden, and 
asked the Sister whether she noticed that the artillery had 
just stopped firing. Gradually getting his bearings, he won- 
dered whether he had been in the hospital since the day 
before. He certainly was not ill, he thought. 

This normal state lasted for a half hour. The patient then 
relapsed into anxious semi-consciousness, becoming deaf 
again and shouting his words. During the next few days 
and weeks he had frequent changes of state like the above 
described. The changes to a normal state would take place 
spontaneously in the absence of apparent occasion, but the 
relapses into semi-consciousness took place when there was 
some outer irritation, especially some noise. Every fright 
would cause a relapse. Once a small cannon fired at a great 
distance off caused such a relapse; again, a sudden shouting 
at the patient. 

During the clear state there was a complete amnesia for 
the period of illness. He did not want to believe that he 
had been in the hospital for weeks, declaring that he must 
have been in the trenches two days before. 

Gradually the semi-conscious states decreased in length; 
the deafness and loud speech returned with the semi-con- 
sciousness. With the return of orientation, the man looked 
entirely normal, speaking in a low voice somewhat shyly. 
He was rather suspicious and could find his way about with 
difficulty. His memory broke off with the last days of 
December, 1914, at which time he was in the trenches under 
intense shell fire. His wife had received no word from him 
since December 26. Even at the beginning of February he 
grew anxiously tense when the word shell was mentioned. 

February 4, Gaupp presented him in clinic as entirely 
clear. He mentioned that his relapses to semi-consciousness 
occurred on the occasion of a loud noise or word spoken. 
His face was contorted at Gaupp's remark but there was no 
other change in him. The next day, however, he told the 
Sister that Gaupp had shouted out once to "get him away." 



496 SHELL-SHOCK: NATURE AND CAUSES 

He said he had then heard artillery fire for a moment, but 
pulled himself together though he had almost gone off, and 
had a violent headache afterward. 

These states of alternating normality and semi-conscious- 
ness continued until about February 10. During a clear 
spell, the patient was quiet, reserved, taciturn, a little ill- 
tempered and seclusive, occasionally writing his wife a rather 
empty letter. In the semi-conscious state he was emotional 
and restless, seeking cover from the enemy. These states 
stopped altogether about the middle of February. He then 
became somewhat more open, though he had no idea of the 
gravity of his condition. He was angered by the window- 
bars, and offended by the opening of a letter to his wife, de- 
claring that he would never write a word again, as it was just 
like a prison. These outbursts passed quickly by. He 
wanted to go home and believed he would soon be able to go 
to his comrades in the field. 

At the time of the report, Gaupp felt that he could not be 
discharged for a number of weeks. He was pallid, gave the 
impression of being exhausted mentally, complained of rest- 
lessness and internal irritation. His memory gap covered at 
the end of March a period of about five weeks: from the end 
of December, 1914, to the beginning of February, 1915. 



SHELL-SHOCK: NATURE AND CAUSES 497 



Frostbite; thrown into water by horse; horse shot 
under its rider who becomes: A HORSE IN THE 
UNCONSCIOUS. 



Case 359. (Eder, March, 1916.) 

A private in the Royal Engineers, 25, went through Gal- 
lipoli without injury and without^: ears. He was sent to the 
hospital in Malta, December 18. When observed by Eder, 
February 7, the frostbitten finger of the right hand was well 
although there was some loss of grip. He was suffering from 
insomnia, terrifying dreams, shaky hands. It seems that 
December 6, a horse started and he was thrown into the 
water from a bridge. The next day his horse was shot under 
him. A few days later, a finger was frostbitten. Then his 
hands began to tremble and the insomnia set in, with severe 
headaches. 

This patient was a jovial, thickset, farmer's son, with a 
diffuse enlargement of the thyroid gland, a high blood pres- 
sure, lymphocytosis, a fine tremor of the hands, irregular and 
rapid pulse, and anginal attacks. Extremities were cold and 
blue; the palms perspired markedly; there was hypersen- 
sitiveness to sound; there were occasional attacks of dizzi- 
ness, with a feeling of suffocation; there was frequent desire 
to micturate. 

The patient's dream was always the same: He saw a 
Frenchman digging a knife into his horse, getting off a cart 
to do this somewhere in Serbia. Occasionally he had this 
dream in the form of a vision in the daytime. It.seems that 
he had actually seen a French soldier plunge a knife into a 
mule to make it go. He had been busy with horses since 
childhood: as stableboy and groom. He thought that the 
sufferings of the mules in Gallipoli were worse than those of 
human beings. According to Eder, this farmer's son was the 
horse of A his dreams ; instinctive fear had to emerge ; he was 
pitying himself. According to Eder, " That the person should 
become a horse in the unconscious would not startle one who 
has dipped into the totems and taboos of the lower races." 



49§ SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; gassing; fatigue: Anesthesias. 



Case 360. (Myers, March, 1916.) 

A stretcher-bearer, 44, eleven years in the service and two 
months on French service, was seen by Lt. Col. Myers eight 
days after reporting sick and admission to a base hospital. 

While he was under cover in a cellar, three days before 
reporting sick, a shell had jammed the door and the fumes 
came in. Later in the day, in another cellar, he had been 
blown off his seat by a shell and six other men had been laid 
out. The shelling continued that day and two following 
days. He had worked on the wounded without any rest. 

On lying down he found his left arm numb and cold. The 
numbness then spread to the legs, especially to the left leg. 
There was continual tingling in terminal joints of fingers of 
left hand; hypalgesia over both forearms and hands, espe- 
cially on left side; total analgesia over left dorsum. 

Two days later, the patient could feel articles and reported 
that the numbness occurred only in the early morning and 
was followed by a tingling as the numbness passed off. On 
the same day, the hands and forearms showed a total loss 
of sensibility to pain, except for a small area on the flexor 
surface below the elbow joint. 

Re spread of anesthesia and alternation of sensory symptoms 
in this case. Babinski, of course, believes, that the majority 
of these conditions are the product of medical suggestion, but 
Babinski meets any critique by pointing out that anyfother 
sort of suggestion may produce such results. The hetero- 
suggestion need not be medical. Thus, the sight of a com- 
rade with paralysis or anesthesia, organic or hysterical, may 
suggest such to the soldier. Leri remarks that these may 
also be produced by autosuggestion alone. "From a tired 
feeling in a limb to a loss of power in it, there is but a small 
step. Another step leads to paralysis and anesthesia. The 
neuropathic temperament takes these small steps in per- 
fectly good faith." Leri has found no case in which he could 
exclude the influence of auto- or heterosuggestion. 



SHELL-SHOCK: NATURE AND CAUSES 499 



Shell-shock; burial; somnambulistic state: Am- 
nesia. Recovery of memory in hypnosis. 



Case 361. (Myers, February, 1915O 

A healthy-looking man, with flushed face and large dark eyes 
with wide pupils, complained of pains in abdomen, back, and 
limbs, chiefly in knees and ankles, and of visual impairment. 
This corporal said that his sight had been very indistinct 
since he was buried, and that if he looked at an electric light, 
he could see nothing for five minutes afterwards. He was 
admitted to the Duchess of Westminster's War Hospital at 
Touquet, December 11, 1914, having been buried for 48 
hours, December 8, when a shell blew in the trench where he 
lay. He said he could remember nothing until he found 
himself in a dressing station, lying on straw, in a barn. He 
was at that time unable to see and fell over something when 
he tried to walk. 

He had gone out August 13, and had been in the last two 
days at Mons and then at La Bassee. He had slept badly 
and had taken a good deal of whiskey. He had led a fast 
life and had had domestic worries recently. 

It appeared that his vision had improved since the day 
of the explosion; though he could read for a short time only 
when things became blurred, and only with the type close to 
the eyes. Bowels had not opened for five days. Vision in 
right eye was 5/60; left eye, 2/60. 

Tested for smell, he failed to smell peppermint, ether, 
iodin tincture, and carbolic acid 1-40. Sugar was tasted 
only after tongue movements were permitted, as was also a 
strong solution of salt. Acid tasted salty like alum. The 
patient complained that he did not sleep, though in point of 
fact he slept well. 

The patient was treated by suggestion, both in hypnosis 
and without, when he was transferred on the 31st of Decem- 
ber, to the London Temperance Hospital, whence he was 
discharged. The treatment by suggestion occurred daily. 
At the second trial and thereafter, light hypnosis was easily 



500 SHELL-SHOCK: NATURE AND CAUSES 

induced, but the deeper stages, with hallucinations, anes- 
thesia, and post-hypnotic anesthesia, could not be reached. 
The lighter stages brought about sleep, a gradual restoration 
of memory, and later an improvement in visual and olfactory 
acuity; in near vision, in visual fields, and in color sensibility. 

The stages in the restoration of memory are as follows: 
December 22, he was able to describe how he was buried, 
how Sergeant L. dug him out, how men of another regiment 
than his own took him to a dressing station, whence he was 
packed off by the M. 0. to the dressing station of his own 
regiment. Capt. S. had spoken to him and given him a 
drink. Post-hypnotic suggestion caused him to remember 
this latter fact after he had come out from hypnosis. 

December 23, even before hypnosis, he could remember 
a big hospital with a stove in the center of a big square room, 
and gave a fragmentary account of struggling in the trench 
after being buried, and of going to sleep and enjoying him- 
self at home, when somebody started messing him about. 
In hypnosis, he gave further details of his dreams after fall- 
ing asleep in the buried state. 

December 26, further details were remembered before 
hypnosis, such as a ride in the motor ambulance, offers of 
tea, cocoa, sweets, and cigarettes, a bad headache, and the 
like. 

December 27, in hypnosis, he was able to describe with 
apparent accuracy the position of the trenches and their 
appearance. He said: 

"The explosion lifted us up and dropped us again. 
It seemed as if the ground underneath had been taken 
away. I was lying on my right side, resting on my 
right hand, when the shell came. I got my right hand 
loose but my wrist was fixed behind a piece of fallen 
timber. At last I dropped off to sleep and had funny 
dreams of things at home. One thing in particular I» 
have thought of many times since, I have not been able 
to make out why I should dream of the young lady 
playing the piano. I don't know her name and I don't 
think I have seen her above twice." 

According to Myers, it is questionable how far the patient's 
memory can be trusted; and there is considerable doubt 



SHELL-SHOCK: NATURE AND CAUSES 50I 

whether the man had remained in the trench for more than 
an hour after the shell had burst. A comrade said that the 
doctors at the barn thought the man off his head. Another 
soldier, familiar with the positions of the regiments in ques- 
tion, gave information suggesting that the patient had wan- 
dered in a somnambulistic state from the trench, past his own 
dressing station to that of another regiment. 

Re Shell-shock and burial cases, compare remarks of 
Grasset and of Foucault concerning the feeling as if dead on 
the part of certain buried persons. Somnambulism is a 
natural sequel to such feelings. For somnambulism, com- 
pare cases of Milian (364, 365, and 366). 



502 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; minor injuries: Somnambulistic 
" carrying on " ; fatigueability, physical and mental. 



Case 362. (Donath, July, 191 5.) 

A lieutenant of infantry, 31, threw himself down on the 
earth September 9, 19 14, as a shell was passing over him. The 
shell exploded and seriously injured a soldier one meter away. 
The lieutenant got up and ran for cover about twenty meters 
distant. Only six and a half hours later did he perceive that 
there was a small skin lesion between his thumb and index 
finger, caused by a shell fragment, as well as a superficial 
burn on his right temple. Neither wound bled or had to be 
dressed. He carried on, aware that they were marching 
toward* the River D. ; but only two or three days later did 
he find they had already marched to the other side of K., had 
rested there and spent the night in various places in between. 
During this whole period the lieutenant led his battalion and 
held a piece of woods without anyone's noticing anything 
striking about him. These dazed states were twice repeated, 
for periods of ten and twenty-four hours respectively, and 
finally he was brought behind the firing lines unconscious. 

The physician found him to be in a state of exhaustion, 
pulse 108, and had him brought to the nearest station. There 
Donath found increased tendon reflexes, some dermatographia 
and increased fatigueability of mind and body. He was 
especially fatigued by walking, though he had always been a 
good mountain climber. He was now unable to concentrate 
on reading, writing or calculating, though he had been 
accustomed to dictate letters and calculations in his official 
work in peace times. He had seizures of crying and trembling 
on September 10 and October 27, both quieted by bromides. 
There was diminution of sexual power. 

Rest, lukewarm baths, cold compresses to the head, and 
psychotherapy improved his status rapidly. 

This patient had never been epileptic or hysterical, subject 
to dazed states of any sort, was weak, delicate and anemic 
(three sisters leukemic) , but had before the war been well. 



SHELL-SHOCK: NATURE AND CAUSES 503 



Emotion of captain who saw men burned by bomb : 
Stupor " as if dead " ; awakening " as if a German 
prisoner." Recovery. 



Case 363. (Regis, May, 1915O 

A captain, one day seeing some of his men hit by incendiary 
bombs, felt the deepest kind of emotion. He threw his coat 
over one of his men and succeeded in smothering the fire. 
Of a sudden, he completely lost consciousness, only regaining 
contact with the outer world two days later, in the sanitary 
train. He did not know where he was, but thought himself 
a prisoner surrounded by Germans. The disorder of con- 
sciousness lasted three days, and the memory of what hap- 
pened during those days never returned. In fact, the 
captain declared that he felt as if he had been dead during 
that time. His dreamlike state lasted for some time, and for 
several weeks he did not sleep without disturbing nightmares. 
It was always the same night attack, with the burned men 
and the anguish of feeling that his men were not about him 
and that he was alone in the skirmish. He later recovered 
entirely and made preparations to start for the front. 

Re feelings "as if dead," see remarks of Regis under Case 
293. 






504 SHELL-SHOCK: NATURE AND CAUSES 



Emotions over battle scenes : Spontaneous hypnosis 
or SOMNAMBULISM lasting twenty-four days. 



Case 364. (Milian, January,i9i5.) 

Upon recovery from a state of apparent hypnosis described 
below, the victim wrote, in part, as follows: 

" After marching two days we reached a Breton 
village near Virtou. Next day we were in a battle that 
lasted from seven in the morning to eight in the evening. 
I was somewhat troubled by the first balls and bullets 
that whistled by, but felt I had to get used to them and 
we marched on, under our brave captain's orders. 
Then we really got under fire. It was sad to see my 
comrades falling under the murderous bullets, and the 
captain was soon mortally wounded; but we had re- 
inforcements and went on and chased the enemy from 
his positions. During the battle I kept thinking of 
my old mother and father and I felt that I should die 
without seeing them again. Little things about the 
family came to my mind. I saw my father's roof, and 
his favorite garden seat, and I saw my mother weeping 
over her only son, her only ambition in old age. The 
return from the battle was very sad for me. Night be- 
gan to fall on the frightful field. I saw on the bare 
earth the bodies of poor comrades whose joys and sor- 
rows I had shared. There they were, cut down in all 
the strength of youth, leaving their parents in trouble, 
their widows in despair, and their poor orphans. I 
wanted to carry them off and I could not. We had to 
march over their glorious remains. I was able to give a 
word of encouragement to one of my comrades who now 
probably is no more. We then retired. Although I 
was very weary, I was unable to get any rest. My mind 
was occupied with the frightful things I had seen. I 
thought of the comrades over there and that no one 
could help them. I remember I drank coffee the next 
morning and talked with my relative. Then that is all. 
From that time I do not know what happened." 

The writer was an -infantryman, 20, who had been employed 
in civil life in the Credit Lyonnais, and was brought August 24, 
1914, to the Saint Nicolas Hospital in a state of hypnosis. 



SHELL-SHOCK: NATURE AND CAUSES 505 

Once placed in the standing position he kept balancing back 
and forth, with head motionless, eyes fixed and directed to the 
left side. He did not speak in reply to a request for his name 
or facts about his life, but as soon as the battle was talked of he 
began an expressive pantomime, speaking in a very low voice 
a few words interrupted by sighs. " What were you doing in 
the fight? " He extended his arms, described a half circle 
with his hand, as if to show the extent of the field, thrust his 
hands forward with a finger outstretched, saying, " Zi, zi," as 
if to indicate whistling bullets; plunged forward with hands 
in front of his chest, as if holding a gun in charge bayonet 
position, saying " Prussians, Prussians," and threw himself 
down in a kneeling posture, saying, " Trenches, trenches." 
"Do you remember the battle?" " Belgium, Belgium. 
Germans pushed back," making a sign as if chasing them. 
"Captain dead. Two hundred men dead." With a suitable 
gesture he sighed, and tears ran down his face. 

August 28 the mutism was still almost complete, but he 
could say his name and lay stretched out on the bed. 

September 4 the hypnosis was less, but the delirious state 
was more active. He got up in the night and tried to escape 
to help the wounded. In the daytime, if he saw a man lying 
down resting he went to him and unbuttoned his coat to see 
whether he was wounded. Upon seeing the physician he 
would cry, "Major! Wounded! wounded!" and then pull 
the physician by his coat. He could hardly be stopped from 
these maneuvers. He had to be fed like a child, but went 
alone to stool. 

He began to be employed about the hospital a little 
September 14, in sweeping the room and in guarding another 
patient in complete somnambulism, over whom he watched 
as over a child, leading him by the hand and keeping him 
from bumping into objects. 

September 16 he awoke suddenly. Some one had talked 
to him about his own village and his relatives. He was aston- 
ished to find himself in a hospital. He wrote out, on request, 
the above account of his recollections. The man was 177 cm. 
tall, well proportioned; showed a slight facial asymmetry and 
a few other facial features of a dystrophic nature, such as an 
adenoid appearance. There was no stigma of hysteria. 



506 shell-shock: nature and causes 



Putative loss of brother nearby in battle: Spon- 
taneous hypnosis or somnambulism ; mutism, except 
" Mamma, Mamma." Sudden awakening after 
twenty-seven days. 



Case 365. (Milian, January, 1915.) 

A man, 22, was brought to the Saint Nicolas Hospital in 
a sort of coma August 24, 19 14. He lay on the bed, eyes 
closed as if asleep, insensible to excitation, irresponsive. 
Flies crawled upon him with impunity. He did not wink. 
The arms raised fell back inert. The corneal reflex was 
absent on the left side, diminished on the right. The knee- 
jerks and the skin reflexes were normal. 

Next day he had to be fed like a child and looked after. 
Lifted from bed, once on the ground he stood up with flexed 
legs, as if to crouch. It seemed as if he was about to fall, but 
he did not. 

The next day he was in the same immobile state. Upon 
removal from bed he again made as if to fall, but got his 
balance. He kept his legs flexed, his head lowered in a fixed 
posture, with his eyes on the ground. He would walk quickly 
without falling, if taken by the hand, feet dragging, and even 
holding back with a certain amount of force. His walk 
suggested that of a somnambulist. He was left in a standing 
posture by his bed throughout the medical visit. After a few 
minutes he began to flex his legs progressively and slowly. 
The attendant cried out, "He is going to fall." Instead of 
falling, he sat down upon the floor near the bed. He was in 
the same immobile, somnolent state September I, eyes half 
open, hidden under long lashes. Flies walked over his eyes 
and lids, but he did not wink. He would rise only when 
pushed and walk only when pulled, but had begun to eat a 
little better. To all questions he replied, from between his 
teeth, "Mamma. Mamma." 

The next day there was a bit more spontaneity in his 
walking. 

Lumbar puncture showed a slight hypertension. There 
were traces of albumin and very few lymphocytes. 



SHELL-SHOCK: NATURE AND CAUSES 507 

September 6, he was able to eat soup alone, but kept 
the same immobile posture, with eyes fixed on the ground, 
eyelids not winking, in a posture suggesting Parkinson's 
disease, but without rigidity. He still replied only, " Mamma. 
Mamma." 

September 19 the patient suddenly waked up completely. 
Douches and external irritations had not served to wake him 
up, but a soldier told him upon this day that his brother was 
not dead, as he believed, but was alive and he then began to 
speak, opened his eyes, and began to talk. He told how he 
had been by the side of his brother in battle. Germans had 
taken them in the flank and opened machine guns upon them. 
Two men had fallen by his side, and, catching at his garments, 
kept him from retiring when the order was given. He got 
loose, looked for his brother among the corpses, could not 
find him, thought him dead, and from that point forward 
had been without memory. He shortly became perfectly 
normal. 



508 shell-shock: nature and causes 



Shell-shock; slight trauma; windage felt; fall; loss of 
consciousness; wandering, conscious, over night; 
shrapnel burst : Spontaneous hypnosis or somnam- 
bulism, lasting four days. Return to the corps. 



Case 366. (Milian, January, 1915.) 

An infantryman, 20, boxer by profession, was brought with 
other wounded, in the night, to Saint Nicolas Hospital and 
was seen next morning, August 24, in bed, lying motionless 
on his back, eyes open, fixed, eyelids not winking. No reply 
was got to questions. The arm lifted f e 1 back upon the 
bed, although slowly and not heavily as in apoplexy. There 
was no catalepsy. The patient was taken from his bed and 
put upright. In this position he remained immobile, hands 
at side, head bent forward, eyes fixed on the ground. The 
eyelids did not move upon approach of the finger or a lighted 
candle, unless there was a fine beginning of movement. If he 
was pushed, he made two or three steps forward, with eyes 
fixed on the ground and head bent forward. The only 
spontaneous movement was carrying the left hand back to 
the side as if to take the bayonet. He got into bed alone. 

Next day the patient could walk better and began to talk, 
but preserved the same absorbed attitude. He told, in 
monotonous voice, of the shells that his squad had received 
and of the dead that he saw about him. August 27 he woke 
up and was unable to tell how he had come to the hospital. 
He told how the regiment had been bombarded for a time 
and how a shell burst near him ; how he got a splinter in the 
buttock (of which the contusion was still visible) ; and how 
he had been thrown down by the windage of the shell. His 
sack had been torn from his shoulders. He had lost con- 
sciousness, he thought, for a short time, anyhow he could not 
find his regiment. He passed the night near Longuyon and 
next day looked for his regiment again. Shrapnel burst near 
him, and from that time forward he had lost memory. Aug- 
ust 27, at his express request, he started back for his corps. 
There was no stigma of degeneration or hysteria. 



SHELL-SHOCK: NATURE AND CAUSES 509 



Burial ; struck in head by beam ; overcome by gas : 
Tremors, convulsive movements, confusion, flight 
toward enemy. 



Case 367. (Consiglio, 1916.) 

An Italian private, 28, of meager build (infantile eclampsia; 
brother epileptic) was buried by a shell explosion and over- 
come by gas. After a month's leave he went back to the 
trenches. 

But now, whenever a shell burst, he fell into irresistible 
terror and made convulsive movements which he forgot after- 
wards. He could not sleep. The mere memory of the scene 
would throw him into terror. He was tremulous, developed 
asymmetrical innervation of his face, was generally hyp- 
esthetic and mentally blocked. 

In the midst of convulsive tremors he fled towards the 
enemy. He was stopped and brought back, and remained 
for two days confused and hallucinated. 

In the original accident he had been struck in the head 
by a beam. 

Re this Italian's flight toward the enemy, see various cases 
of fugue. Clinically and medicolegally, Roussy and Lher- 
mitte remark that these confusional escapades are of great 
interest, and that many cases are encountered near the 
front line, put under trial by court-martial, and handed 
over to specialists. The dream is being lived through. 
Such a case as this of Consiglio recalls the hystero-emotional 
psychoses of Claude, Dide, and Lejonne. The relation of 
oniric delirium to mental confusion is still a matter of polemic. 
According to Regis, however, the common oniric delirium of 
toxic or infectious origin is nothing more than a sort of 
somnambulism. The retrograde amnesia which follows toxic 
delirium is the same in principle as that which follows 
hysterical delirium. Regis pointed out that suggestive hyp- 
nosis could bring back the memories in both types of disease, 
as well as from the toxic delirium as from the hysterical som- 
nambulism. However, the differential diagnosis between 
onirism and hysteria is not easy. Alcoholism and actual 
brain trauma need to be excluded. 



510 SHELL-SHOCK: NATURE AND CAUSES 



Shell-shock; windage; unconsciousness: Carried 
on with fugue tendencies. Variety of hysterical 
symptoms. Fit for garrison duty four months from 
explosion. 



Case 368. (Binswanger, July, 1915.) 

A non-commissioned officer, 22, entered service at 20, went 
into the artillery and had been advanced repeatedly. There 
was no heredity; the man had been a moderately good 
scholar. It appears that he had had at 17 a febrile angina 
with delirium. 

September 25, 1914, a big shell load for a cannon was 
exploded by the enemy. All the men about the cannon were 
thrown to the ground by air pressure, and the officer became 
unconscious. On awaking, he had headache, dizziness, and 
vomiting. There were many corpses lying about him. 

He resumed work at once, but in the evening his headache 
and dizziness increased and there was "a feeling inside as if 
he had to run away." This feeling appeared to come from 
the heart ; it was an oppressive feeling, running to the head. 
On the next day he did gun duty, noticing, however, that 
every shot he fired caused him a sharp pain. He was relieved 
from work at 11 a.m., and was declared ill by the physician. 
His comrades told him that he had often been noticed trying 
to run away, but about this he himself declared he knew 
nothing. 

He was received at the Jena Hospital, October 9, 1914, a 
very strongly built and well-nourished man. Neurologically, 
he showed a marked dermatographia ; knee-jerks were 
obtainable only on reinforcement; Achilles jerks somewhat 
more marked ; there was a weakly positive Oppenheim reflex. 
The abdominal reflex on the left side was greater than that 
on the right; and this was also true of the cremaster reflex. 
Percussion of the head was extremely painful ; and there were 
painful points on pressure of the spine and head. 

Touch was poor on the entire left side of the body; but 
there was no diminution of sensibility to pain. There was 



SHELL-SHOCK: NATURE AND CAUSES 511 

a fine static tremor of the hands. The strength of both 
hands appeared to be decreased (dynamometer). Gait was 
unsteady and stiff; Romberg sign was positive; the patient 
fell over backward. Hearing was greatly diminished, ordi- 
nary speech being heard only close to the ear. 

Toward evening of the second day after admission, there 
was a marked attack of dizziness while the patient was lying 
on his back in bed. During this attack the face was very 
red. It lasted two or three minutes. Hearing was remark- 
ably improved on the left side for some time after the attack. 
The ear clinic examination, October 19, showed much dis- 
turbance of hearing on the right side (direct injury of the 
vestibular apparatus in both ears). 

Headaches continued, radiating from the orbit to the top 
of the head, and sensitiveness to pressure at the exit point 
of the upper branch of the right trigeminal. The whole of 
the forehead was somewhat red and swollen (neuralgia of the 
frontalis). The patient wore dark goggles on account of his 
marked photophobia. 

Improvement was gradual; there was a transient slight 
swelling and a venous hyperemia of the nasal mucosa, which 
was treated in the nose clinic. The impairment of hearing 
was quite gone in two months' time, though buzzing was now 
and then heard in the right ear. The supersensitiveness in 
the right upper trigeminal region vanished also. The patient 
was discharged January 21, 191 5, fit for garrison duty. 
Later he went into the field again. 



512 SHELL-SHOCK: NATURE AND CAUSES 



Burial : Dissociation of personality. 



Case 369. (Feiling, July, 191 5.) 

The following are some stories told by a "lost personality " 
under hypnosis. 

The patient, aged 24, was a bandsman in the Second 
Battalion Wiltshire Regiment, who sometime near the end 
of October 19 14, was buried in a trench near Ypres. This 
is his account: 

11 1 was dug out at night and taken to a dressing station; it 
was cold and dark. Then I went on to a hospital at Ypres; 
it was really a convent, and there were a lot of nuns about, 
dressed in dark robes with white hats; some of them spoke 
English. I stopped there for a night and a day. There were 
a lot of wounded there. Then I was sent on by train; I lay 
down all the way on a seat in the carriage; we took the 

whole day to get to , and kept on stopping at stations. 

I was at about ten days; I don't know what hospital 

it was, but there were English doctors and nurses. It was 
near the harbor. We came over to England in a hospital 
ship, the Areihusa; I went straight on to Manchester by 
train. The hospital there was really a school turned into a 
hospital. 

Here is a brief account of a scrap with some Uhlans. 

Q. Did you see any Uhlans? Yes. 

Q. What are they like? They've got no guts. One time 
30 of them were against 8 of us infantry, and they "done a 
bunk." Their horses were not bad. They wore helmets 
with a double eagle on the front. 

He was asked to describe the country round the trenches 
and to give some account of the fighting there : 

"It's agricultural land, ploughed fields. There were two 
farms in front of us. One day we saw an old cow between 
our trenches and the Germans, and we all had pot shots at it. 
Once the Germans rushed our trenches; we killed hundreds, 
bayoneted them mostly, and hit them over the heads with 
the butts of our rifles. It was hellish. The British were all 
shouting. I saw a German officer behind with a sword and 



SHELL-SHOCK: NATURE AND CAUSES 513 

a revolver. I saw a lot of French soldiers, too; they wore ^ 
long coats with the corners turned back; some had blue and 
some had red trousers. The French dragoons are like Life 
Guards, with big steel breastplates and brass helmets with 
a long plume; they carried swords and rifles and a few had 
lances." 

He was asked to mention some of his impressions in Bel- 
gium and what he thought of the manners and customs of the 
French and Belgians. 

"We cut off all our buttons and gave them to the French 
girls. The French cigarettes are muck; you buy them in 
little blue packets; the tobacco is rather dark and strong. 
When we bivouacked on the march at night we were not 
allowed any lights, but you could smoke by digging a hole in 
the ground with your bayonet and smoking into that." 

The following are some of his remarks about his stay at 
Gibraltar. 

"Gibraltar's like a great big rock; the steep side looks 
toward Spain. I was in barracks there, and used to spend a 
lot of time in the band-room practicing. Sometimes we 
bathed in the sea. I went to Spain two or three times and 
saw some bull- fights ; they were very exciting, but rather too 
cruel for my taste. They used to kill six or seven bulls a 
day. The horses got fearfully cut about." 

This bandsman showed what Feiling calls dissociation of 
personality. There was an amnesia of such degree that all 
conscious memories of the patient's life, as well as all memory 
of letters, objects, and life in general, were suppressed. The 
patient was brought, after the burial above noted, to the 
hospital for epilepsy and paralysis at Maida Vale, January 21, 
191 5. After his experience, he had been transferred to the 
Second Western General Hospital, Manchester, where he 
spoke sensibly, understood and was able to remember things 
since the burial. His mind was a complete blank for all 
previous experience. He was unable to recognize his own 
father or relatives. He was slightly deaf for a time but this 
defect disappeared. 

At Maida Vale he showed a nervous twitching of eyelids 
and facial muscles; otherwise he was neurologically and 



514 SHELL-SHOCK: NATURE AND CAUSES 

physically normal, dreamless, without complaints, and 
straightforward about all experiences since coming to himself 
in the hospital at Manchester. He took his parents on trust. 
"I don't know if I ever went to school." "A bayonet is like 
a knife; you see soldiers with them on their rifles. I have 
never seen a bullet." His memory for recent events was also 
not good. He once recognized a single tune played at a 
concert. 

Suspected of malingering, he was tried out in various ways. 
He was told that an elephant was a little furry animal and 
shown a little 6 inch toy sample. On going to the zoo he was 
greatly astonished at seeing a real elephant He did not 
know what the war was about and he had no interest therein. 

March 10 he was hypnotized and proved an easy subject. 
Powerful suggestions that lost memories would return were 
unavailing. The next day, during hypnosis, it was found 
that his previous experience could be readily tapped, and a 
history of his family, schooling, running away, and eventual 
enlistment was told. He had been at Gibraltar when war 
broke out. He was at the first battle at Ypres, and was for 
ten days in severe trench fighting, and was finally buried in 
the mud and debris of a trench blown in by a high explosive 
shell. He had been buried for about 12 hours, was dug out 
at night, and (according to his father) remained unconscious 
24 hours, and deaf and dumb three days. He was trans- 
ferred to another hospital and then to Manchester, where he 
came to himself. 

Only during the first few sittings did the patient lie with 
eyes closed. Later, during hypnosis, he behaved exactly like 
a normal person. The fact came to light that when hypno- 
tized the patient returned to the personality that possessed 
him just before awakening in Manchester, and accordingly 
during hypnosis, he had to become acquainted again with his 
hypnotizer. Maida Vale astonished him, as it should have 
been Manchester. Thus there were two personalities : No. 1 : 
The personality since the date of the Manchester awakening; 
No. 2: The personality containing all the memories of the 
past life as well as the more recent Flanders memories. In; 
State No. 1, the manner was jaunty and cocksure. In State 



SHELL-SHOCK: NATURE AND CAUSES 515 

No. 2, the man was more modest and less loud. Moreover, 
though in State No. 1, he spoke with a Lancashire accent, in 
State No. 2 his speech was in the West Country dialect — a 
strange observation, confirmed by several observers. He 
was asked to write down the answers to questions, and on 
awakening from hypnosis was shown the things written; 
whereupon he laughed and said, "Why, that's not my 
writing." On writing out the same sentences again, various 
minor points of difference were apparent. Hypnotized in 
the presence of his father, in whom in State No. 1 he took no 
great interest, he showed every sign of joy, causing his father 
to think that in State No. 2, his son had "come all right 
again." In State No. 2 he could play a euphonium better 
than in State No. 1 ; but after practicing in State No. 1 he 
rapidly became as expert as in the hypnotic state. 

If the patient were left for some time before being awaked 
by a previously-arranged method of counting three, he would 
experience disturbed dreams, with clenched hands, snarling 
lips, and muttered phrases, "Give it them," etc. 

Twenty-five hypnotic sittings were given but no improve- 
ment took place and the patient was discharged May 5. 
May 25 there had been no further change and he remained 
in State No. 1, in which state he was invalided from the 
service by a medical board, May 28. 



516 SHELL-SHOCK: NATURE AND CAUSES 






Ear complications and hysteria. 



Case 370. (Buscaino and Coppola, 19 16.) 

An infantryman, 22 (father and mother quite normal; 
patient showed slight convulsions, attributed to worms, from 
which he actually suffered; was malarial from 9 to 15; had 
otitis media and lost hearing completely at 1 1 ; had suffered 
from 9 onwards with joint pains; as an adult had no con- 
vulsions), was called to arms August, 1914, and sent to the 
front May 2, 191 5. About the end of August, in a water-filled 
trench by Monte San Michele, he was covered with mud from 
a shell explosion, lost consciousness, and in some way got 
back to the second line. He was told that blood had flowed 
from the right ear, and on recovery he found himself unable 
to hear with that ear, although it was the left in which he 
had had otitis. There were continual noises in the ear. He 
was, however, sent back to the front line. By mistake, one 
day, he got with companions in the midst of the enemy's 
barbed wire, saw sparks from the guns, heard no shots, saw 
comrades fall, and threw himself instinctively into the wire 
network. Leaving the food kettles, he finally got back to 
the trenches. He was sent to the hospital at Legnano for 
his ear pains, and was treated by leeches, which he could not 
feel. He began to hear a little more. Flies walked on the 
left cheek without being felt. This anesthesia had begun a 
few days after the shell explosion. He was transferred to a 
military hospital at Florence. 

One day he wedged a toothpick in cotton into his left ear 
and was charged with simulation, though he had been abso- 
lutely deaf in his left ear since childhood. From the moment 
the military surgeon told him he would be denounced for 
simulation, he lost his memory. Reports indicate that he 
had headache and delirious dreams (October 30), and sud- 
denly he became furious (October 31), about three hours 
later going into severe collapse, for which camphor injections 
were given. 

November 1 he had battle dreams and lumbar puncture 
had to be given up as he was in the midst of an attack. A 



SHELL-SHOCK: NATURE AND CAUSES 517 

hypodermic injection was interpreted by the patient as a 
wound, and he cried as if he were being abandoned on the 
battle-field. At one point he woke up from his hallucination 
and asked where he was and shortly relapsed into stupor. 
November 2, the patient was slightly bewildered and felt 
pains where the lumbar puncture needle had been tried the 
previous day. November 5, he was disoriented, thinking 
himself still at Legnano. The pupils were throughout di- 
lated. November 6, confused and dreamy; November 7, 
he soiled his bed, was somewhat disoriented, immediately 
corrected himself; oculo-cardiac reflex 64 full compression, 
62 during compression. November 11, headache; Novem- 
ber 12, a slight bewilderment reappeared; November 13, 
remembered for the first time having been stunned by shell 
explosion, and this day got up and wrote home. November 
14, complained of pains in muscles and weariness. Pupils 
still dilated. November 16, pulse 86; a gradual increase 
from 50 to 60 during previous days. November 17, patient 
had begun to remember facts that preceded the dream syn- 
drome. November 18, pulse standing 88; November 20, 
pulse standing 120. This day cried when he remembered 
having been suspected of simulation. November 22 and 23, 
aches in joints and intense otalgia; pulse 86. November 
24, diarrhea; deafness somewhat diminished; 26, diarrhea; 
looked as if he were about to have a new hallucinatory 
episode. This, however, did not come about until December 
1, when he heard cannonading and knew the regiment was 
near. Next day he had forgotten the cannonading. Decem- 
ber 14, the patient had become entirely tranquil and lucid 
and was able to give his entire history. December 16 and 
17 he was given a systematic neurological examination, which 
showed on the left side complete anesthesia, hyperesthesia 
to pressure, thermanesthesia, analgesia, loss of bone, tendon, 
and muscle sensation. Vision was diminished more on the 
right side than on the left, and the visual fields on this side 
were more contracted. During examination, the fields be- 
came still more tubular. There was complete deafness, 
anosmia, and ageusia on the left side. On the right side 
there was a slight diminution of hearing. The pharyngeal 



51 8 SHELL-SHOCK: NATURE AND CAUSES 

reflex was abolished; the cremasteric reflex was somewhat 
less on the left than the right; and the defensor reflexes of 
the left leg were less marked than those of the right. There 
was no clonus or Babinski. The dynamometer grasp on the 
right was 37; on the left 18; and on this side there was a 
limitation of voluntary movements. 



shell-shock: nature and causes 519 



ETIOLOGY OF SHELL-SHOCK 

WOUNDS 14 of 150 

PHYSICAL 
Exhaustion From Exposure, Hardship (all neuropaths) 3 of 142 
Concussion 52 of 142 

CHEMICAL — Shell Gas 3 of 150 

PSYCHIC 
Gradual Exhaustion, Predisposing (43 neuropaths) 51 of 132 
Same, Acting Per Se (patients chiefly neuropaths) 
Sudden Shock 

Horrible Sights 51 of 142 

Losses of Companions 

Fright Near Explosion (one neuropath) 

Sounds (a few neuropaths) 

RELAPSES (41 of 150 observed, three-quarters neuropaths) 

After Wiltshire 



Chart 10 



Che non e impresa da pigliare a gabbo 
descriver fondo a tutto l'universo, 
ne da lingua che chiami mamma e babbo. 

For to describe the bottom of all the universe 
is not an enterprise for being taken up in sport, 
nor for a tongue that cries mamma and papa. 

Inferno, Canto xxxn, 7-9. 



520 



C. THE DIAGNOSIS OF SHELL-SHOCK 

In the course of our study of psychoses incidental in the 
war (Section A) and especially of Shell-shock's nature and 
causes (Section B), we have naturally met most if not all of 
the major diagnostic difficulties. In the present Section we 
shall study cases for the light they may throw on the more 
technical troubles of the diagnostician. Who would d, priori 
have felt that such diseases as tetanus, rabies, malaria, would 
produce practical difficulties in clinical diagnosis in the field 
of Shell-shock? 

Mayhap there was no need to emphasize further the values 
of lumbar puncture fluid examination. Yet the admixture of 
"functional " and "organic " symptoms in numerous puzzling 
cases can hardly be over-emphasized. 

But the interpolation, through the ingenious inquiries of 
Babinski, of a new or but vaguely suspected series of "re- 
flex" (" physiopathic ") troubles between the organic neuro- 
pathic disorders on the one hand and the hysterical psy- 
chopathic disorders on the other — the result of these 
observations, sampled only in Section B, is given more in 
detail in the present Section. What a split in therapeutic 
method a recognition of this new group of "physiopathic " 
disorders might entail is seen also in further cases in the 
Section that follows this (Section D on Treatment and 
Results) . 

A number of simulation cases has been added. 



52 1 



522 THE DIAGNOSIS OF SHELL-SHOCK 



ETIOLOGICAL GROUPING OF WAR 
PSYCHONEUROSES 

I. NEUROSO-ORGANIC ASSOCIATION (no causal nexus) 
II. REFLEX NEUROSES (lesion disproportionately slight by 

COMPARISON WITH PSYCHONEUROSIS) 

III. NEUROSO-SOMATIC ASSOCIATION (Trench Foot, Neu- 

ritis, Radiculitis) 

IV. FATIGUE OR EMOTIONAL PSYCHONEUROSES (consider 

EFFECTS OF PSYCHIC CONTAGION, EDUCATION) 

V. PSYCHONEUROSES ON ANTEBELLUM BASIS 

After Grasset 



Chart ii 



THE DIAGNOSIS OF SHELL-SHOCK 523 



WAR PSYCHONEUROSES 
SYMPTOMATIC GROUPS 

I. EMOTIONAL (Hyper- Hypo- Para-) 

II. CONFUSION AL (Attention and Memory Disorder, 
Dream States; Deliria) 

III. CONVULSIVE AND PITHIATIC (Hysterical) 

IV. NEURASTHENIC AND PSYCHASTHENIC 

V. SENSITIVOMOTOR AND SENSORIMOTOR — e.g., Limited 
Paralyses, Contractures, Deaf-mutism 

VI. COMPLEX 

VII. PHYSIOPATHIC (Babinski) 

After Grasset 



Chart 12 



524 THE DIAGNOSIS OF SHELL-SHOCK 



Value of lumbar puncture. 



Case 371. (Souques and Donnet, October, 1915.) 

A colonial soldier arrived at Paul-Brousse Hospital with 
a hospital ticket showing that ten days before he had had 
commotio cerebri. He was dull, had a fixed stare, held his 
head in his hands, was disoriented for time and place, and 
had lost memory for everything that had happened for 
eighteen months. There was no sign of wound. There was 
no motor disorder save that walking was a bit slow and 
uncertain. Perhaps the right knee-jerk was stronger than 
the left. Percussion of the right Achilles tendon produced 
tremor. The plantar reflexes were flexor on both sides; 
flexion lasted longer right than left. The cremasteric and 
abdominal reflexes were a little weaker on the right. Arm 
reflexes were lively. Sensations proved normal. Complaint 
of headache, frontal and vertical. 

Lumbar puncture October 7, that is, on the thirteenth 
day after the shell-shock, yielded a transparent, slightly 
greenish fluid, with 92 cells per cm. (lymphocytes with one 
or two large mononuclear cells and a few sometimes degen- 
erated endothelial cells) and hyperalbuminosis. 

October 9, the clouding of consciousness was less marked. 
The headaches and amnesia were constantly complained of; 
the reflexes were normal. October 12, there was less head- 
ache. October 25, another lumbar puncture showed but 14 
or 15 lymphocytes per cm. and hyperalbuminosis. There 
was now no longer any clouding of consciousness. The 
amnesia, retrograde and anterograde back to May 9, 1914 
(date of his daughter's birth), and up to September 25, 1915, 
persisted. The man did not remember the declaration of 
war, or the mobilization, or his regiment, and the like. 
Meantime, the man's judgment and reasoning powers were 
normal. 

If there had been no early spinal fluid examination of this 
patient, he might well have been considered an hysteric or 
even a simulator. 



THE DIAGNOSIS OF SHELL-SHOCK 525 



Meningeal and intraspinal hemorrhage: Lumbar 
puncture. 



Case 372. (Guillain, May, 1915O 

A gunner from Morocco, who lost consciousness for an 
hour March 28, 19 15, upon the explosion of a large-calibre 
shell in his trench, was carried to the ambulance. He 
complained of headache and generalized pains. His status 
was scarcely modified during five weeks, and a generalized 
contracture of the body developed whenever movements 
were attempted. In horizontal decubitus, the muscles of the 
limbs and neck were of a normal tonicity, but the head went 
into hyperflexion if the patient was asked to sit. The eyes 
turned upward, and Kernig's sign developed. The patient 
could walk only with short steps, with legs apart and arms 
held away from the body, the head in a sort of tetanoid 
dorsal hyperflexion. There was a right-sided hemiparesis 
with trepidation and the Babinski sign. 

Lumbar puncture assured the diagnosis of something 
organic. The fluid contained blood cells and a marked 
lymphocytosis. The symptoms evidently depended upon 
hemorrhages in the meninges and the nervous system, affect- 
ing particularly the right pyramidal tract. 

Re hypothesis of organic changes in hysterical cases, 
Roussy and Lhermitte remark in comment upon albumi- 
nosis in the cerebrospinal fluid that the albumin is perhaps 
due (in cases of camptocormia) to the effect upon venous and 
lymphatic circulation of the spinal curvature. It was Sicard's 
claim that camptocormia, or bent back, was due possibly to 
anatomical changes in the spinal column, that is, that camp- 
tocormia was in one sense a spondylitis. In other cases the 
camptocormia might be due to a ligamentous or muscular 
change; that is, to a syndesmitis or a psoitis. His idea was 
that the curvature was in a sense antalgic; that is, a re- 
sponse having the purpose of avoiding pain. 



526 THE DIAGNOSIS OF SHELL-SHOCK 



Slight hyperalbuminosis. 



Case 373. (Ravaut, August, 1915.) 

A farmer, 32, in the 66th Infantry, was lying in a dug-out 
March 5, 191 5, when a bomb threw him on the ground 
and covered him with earth. He was picked up uncon- 
scious, and remained so for an hour. In the ambulance 
it was found that he could hardly stand, could not speak, 
and appeared to be completely confused. There was no sign 
of wound. The next day he recovered consciousness and 
complained of a violent headache. He was completely deaf 
in the left ear, and vision was also a little impaired on that 
side. The puncture fluid was clear, and there was a very 
slight excess of albumin by the heat test. The next day the 
headache had entirely disappeared, the left ear was abso- 
lutely deaf, but the patient complained of buzzing. Lumbar 
puncture the following day showed a normal amount of 
albumin. 

March 16 the patient was evacuated to the rear presenting 
no abnormal symptom except deafness. 

Re the spinal fluid, Armstrong- J ones considers that a 
shock directly sustained by the spinal apparatus through 
sudden impact to the surrounding cerebrospinal fluid, ought 
to be felt more by the anterior horn cells than by the spinal 
root ganglia, since the latter are shielded by the sheath in 
the intervertebral spaces. Motor symptoms would, natur- 
ally, then be more frequent than sensory symptoms. He 
also believes that the controlling neurones in the intermedio- 
lateral tracts that have to do with the sympathetic system, 
would be affected just as anterior horn cells are. Accordingly, 
the dilated pupils, rapid heart, dyspnoea, and a variety of 
precordial pains and disorder of the viscera would ensue. 
The jar would thus be communicated to the neuronic cells 
of origin of two types: spinomuscular and preganglionic, 
leaving the gangliospinal neurones relatively intact. 



THE DIAGNOSIS OF SHELL-SHOCK 527 



Paraplegia, organic: Lumbar puncture. 



Case 374. (Joubert, October, 1915.) 

A gunner, 23, was thrown to the ground, according to his 
story, by the explosion of a large-calibre shell, at eight o'clock 
in the morning of September 10, 19 14. He could not get up 
but thought he had not lost consciousness. September 13, 
he arrived at hospital, looking like a man with dorso-lumbar 
fracture of the spine. There was, however, no external in- 
jury. There was a marked paresis of the right upper extrem- 
ity, with diminished sensibility, weakened reflexes, numbness, 
formication. The right lower extremity was subject to com- 
plete flaccid paralysis, with lost reflexes, and anesthesia in all 
respects reached to the belt level, and stopped sharply at the 
median line of the abdomen. The left leg, also, was paretic 
but the muscles could be contracted weakly; the knee-jerk 
was exaggerated; there was a tendency to epileptoid trepi- 
dation, and the sensations were only slightly diminished. 
There was a Babinski reflex on the right side ; the abdominal 
reflex was absent on the left side; both cremasteric reflexes 
were present. The feet at times gave formication. Rectal, 
bladder, and sphincter paralysis. Dark albuminous urine, 
with a few blood cells, was obtained on catheterization. 
There was an early sacral decubitus; consciousness was 
somewhat clouded. The man made no requests except for 
something to drink, and seemed apathetic. 

Lumbar puncture, September 14, yielded hemorrhagic fluid. 
Three days later, the upper extremity regained its powers 
and sensations, but the paraplegia had become complete, 
with abolition of reflexes on both sides, and absolute anes- 
thesia. The feet yielded formication at times, however. 
Sacral decubitus increased and healed not. The tempera- 
ture varied between 38 and 39. The patient died September 
24, in coma, with anuria and Cheyne-Stokes breathing. 



528 THE DIAGNOSIS OF SHELL-SHOCK 



Gunshot wound of spinal column; no penetration 
or injury of dura mater : At first quadriplegia ; later 
cerebellospasmodic type of disorder. 



Case 375. (Claude and Lhermitte, July, 191 7.) 

A soldier, 22, sustained a gunshot wound in the neck 
about the level of the fourth cervical vertebra. He im- 
mediately became quadriplegic. He recovered arm motion in 
two months and some weeks later ability to stand and walk. 

Three months after the injury, station was difficult, better 
on a broad base. Rombergism, even with eyes open. Cere- 
bellospasmodic gait. There was no weakness of leg muscles, 
but there was a certain degree of weakness of the upper ex- 
tremities, especially in finger flexion. There was hypertonia 
of the muscles of all the extremities and the hands showed 
the signs of Raimiste, of Klippel and Weil, and of Dejerine. 
Static equilibrium was preserved to the will, but the kinetic 
balance was affected, and as much in the upper as in the 
lower extremities. Ataxia, tremors, dysmetria, adiadocho- 
kinesia, and disorder of combined movements in thigh and 
trunk flexion were all in evidence. Meantime, there was no 
disorder of sensation whatever except that the ulnar border 
of the right hand showed a hypobaresthesia, and there was a 
disturbance of tactile discrimination and absolute astereog- 
nosis in the hands. The deep reflexes were everywhere in- 
creased, and ankle and patellar clonus were easy to excite, 
especially on the right side. Bilateral defense reflexes. Bi- 
lateral Babinski sign. The hypertonia and ataxia ebbed 
away during the following three months. Walking became 
normal, and there was little sign of difficulty except astereog- 
nosis of both hands, combined with slight disturbance of 
deep sensibility and poor response to compass test in palm. 

We here deal with a case of spinal column injury without 
injury to the dura mater. This cerebellospasmodic form of 
the superior cervical type of spinal concussion is less frequent 
than a quadriplegic form with Brown-Sequard syndrome. It 
is striking that both types of concussion may recover. 



THE DIAGNOSIS OF SHELL-SHOCK 529 



Spinal column trauma, with local signs: Later, 
hysterical anesthesia and contracture of back mus- 
cles homolateral with the trauma. 



Case 376. (Oppenheim, July, 191 5.) 

A musketeer, wounded August 20, 19 14, by a shell splinter 
in right side of vertebral column, fell unconscious, but was 
able afterward to crawl on all-fours out of the firing line. 
Severe vomiting and epistaxis followed. August 23, there 
was pain in the small of the back; the last two ribs were 
painful on right side; and the muscles were slightly swollen 
up to the iliac crest. August 30, a slight rise of tempera- 
ture (at first it had been above 38) still persisted, but the 
muscular swelling was diminished. Treatment by aspirin 
and baths. No further rise of temperature after early in 
September. 

On October 9, patient was permitted to get up, whereupon 
he showed a peculiar curved attitude of the body, reduced 
almost completely by passive straightening. Swelling of the 
longitudinal muscles. Radiograph negative, except that one 
picture showed a change in left twelfth rib, near the trans- 
verse process. Pains in left lumbar region. 

November 19, on examination, pulse 112. November 23, 
after massage, vomiting. Temporary use of plaster corset. 

On admission to the nerve hospital December 22, the mus- 
keteer was unable to extend the trunk, and the long muscles 
of the back were on the stretch, often as hard as wood, 
especially those of the left (longissimus dorsi). Patient lay 
on right half of pelvis. Hemianesthesia and hemianalgesia, 
left side. Tachycardia. Formerly the patient had done 
hard work, especially carrying heavy bags. He declined to 
be examined under general anesthesia. He seemed to be 
of unreliable character, and his trouble did not prevent him 
from returning from leave of absence, on one occasion, drunk. 



530 THE DIAGNOSIS OF SHELL-SHOCK 



Mine explosion: Combined hysterical and lesional 
effects. 



Case 377. (Dupouy, September, 1915.) 

A lieutenant, 23, was in a mine explosion June 23, coming 
out in complete torpor, with mutism and retention of urine. 
He was brought to hospital June 26, with jactitation, irreg- 
ular pulse, markedly exaggerated tendon reflexes, absent skin 
reflexes, sluggish, dilated pupils, especially right, and general 
anesthesia. The spinal fluid contained an excess of albumin, 
altered blood cells and many lymphocytes. 

Several hours after puncture he suddenly demanded where 
he was, thought it was the year 191 1 when he was in the 
Dragoons, talked about his camp, and was confused, irritable 
and stereotyped in questions. There was no verbal amnesia. 
Speech was hesitant, explosive and scanning, suggestive of 
multiple sclerosis. Next day there was still retrograde 
amnesia. He clung to the belief that it was July, 191 1, 
and asked wearisome, stereotyped questions. The words, 
"German house " caused a jactitation, stiffening and relapse 
into a second Stat, out of which he came with hiccoughs and 
sighs, and amnestic for this conversation. There was general 
hypesthesia and muscular weakness especially of legs. The 
reflexes were as before. 

The morning of June 28, he heard the hum of an airplane, 
whereupon his memory returned. It seems that he had him- 
self once ascended. The memory gap was now limited to the 
time immediately preceding the mine explosion and the days 
following, up to the time of hearing the airplane. He told 
about his military life and also about incidents immediately 
preceding his blowing up. He complained of malaise and of 
pains in the vertebral column and limbs. 

There was a quadriparesis, more marked, however, on the 
left; walking with falls to the left; astasia with left foot; 
double facial paresis; inability to whistle and to close eyes 
completely; intestinal and bladder paralysis; nocturnal 
emissions non-pleasurable; partial anesthesia of right leg, of 



THE DIAGNOSIS OF SHELL-SHOCK 53 1 

arm and of hand, with hyperesthesia of thigh, of forearm and 
of the posterior aspect of the upper arm; anesthesia of the 
left side, including thorax and abdomen, excepting that the 
arm was hypesthetic only. Face hyperesthetic. Com- 
plete anesthesia of nipple and testis; hypesthesia of neck; 
anesthesia of tongue, nose and vertex; plantar, cremasteric, 
abdominal reflexes absent; exaggerated tendon reflexes; 
pupil reflexes normal ; painful heat flashes and profuse sweat- 
ing on the slightest movement; vertigo and tendencies to 
syncope after effort; explosive, scanning speech; inter- 
mittent convulsive movements of the arms. Palpation and 
X-ray show separation of the spinous processes of the third 
cervical vertebra. 

Improvement was marked and progressive in motor, sen- 
sory and reflex fields. At the time of report three months 
later, there was a definite paresis of the left leg, with anes- 
thesia and absent plantar reflexes, and slight paresis of the 
orbicularis palpebrarum, scanning speech and syncopal tend- 
encies. Here, then, due to diffuse, non-systematic lesions, 
with superadded hysterical manifestations, were probably 
some effects of a permanent nature due to destructive 
processes. 

Re combination of functional and lesional effects, Sollier 
and Chartier state that in Shell-shock hysteria, physical 
causes and conditions are the chief factors; that in the so- 
called hystero-traumatism of Charcot, the psychic and 
physical factors are of virtually equal importance, and that 
in ordinary cases of hysteria, the psychic is the chief genetic 
factor. 



532 THE DIAGNOSIS OF SHELL-SHOCK 



Shell explosion: Hysterical and organic symp- 
toms. 



Case 378. (Hurst, 1917.) 

A champion heavy-weight boxer, 29, was unconscious for 
two days after being knocked over by the explosion of a shell 
in December, 19 14. He found at first that he could not 
move the right arm or left leg; and after power had returned 
to the limbs, he had forcible involuntary movements in the 
left leg whenever he tried to stand. Examined, April 1 , 
191 5, he answered questions slowly and with slow words; 
the right arm was weak. When the left hand was clenched, 
an associated movement took place in the right hand, but not 
vice versa. There was, however, no diminution in the girth 
of the muscles. The man was unable to localize light tactile 
stimuli accurately. Movements of the left leg were some- 
what weak, the left knee-jerk was slightly brisker than the 
right; ankle clonus could be obtained on the left side and 
Babinski second sign (paralyzed leg rising higher than the 
normal leg in combined flexion of thigh and pelvis). When 
the man tried to walk, the left leg moved rapidly from side to 
side round the point of contact of the toes. When the right 
leg moved forward, the left dragged behind in irregular 
movement. 

Every effort to cure the patient by means of suggestion 
during hospital care for a month entirely failed. Although 
the man was easily hypnotizable, he could not be made to 
move his leg under the deepest hypnosis. The first whiff of 
ether hypnotized him, so that the method of etherization 
could not be used in the endeavor to control the leg move- 
ments. Over a year later, July, 191 6, the patient had greatly 
improved mentally but was otherwise in precisely the con- 
dition that is above described. 



THE DIAGNOSIS OF SHELL-SHOCK 533 



Gunshot wound of buttocks with injury to cauda 
equina: Urinary disturbance; decubitus; anesthe- 
sia. Superimposed paraplegia, regarded as func- 
tional and cured by psychotherapy. 



Case 379. (Oppenheim, July, 1915.) 

A German grenadier, October 11, 19 14, was wounded in 
the left buttock by a missile that passed out through the 
right buttock. Pains in the abdomen and legs followed. 
The man had to be catheterized on the battle-field. 

October 23, he suddenly fell down with total paralysis of 
both legs. 

November 3, numerous small furuncles appeared on the 
buttocks, and bedsores developed. The patient lay helpless 
in bed, was unable to sit up without support, or to turn from 
one side to the other, and had areas of anesthesia. 

During November and December, there was persistent 
high temperature, between 38 and 40; but January 3 the 
temperature stood at 36.6. 

January 7 the patient was admitted to a nerve hospital. 
At this time he was able to pass urine unaided, though with 
tenesmus and pain, sometimes nausea and a tendency to 
vomit. He complained of pain in the back and pelvic region; 
the legs lay as if paralyzed. No active movement whatever 
was performed, There was a marked increase of tendon 
reflexes (even including the semi-membranosus) . The mus- 
cles were relaxed through disuse but there was no atrophy. 
The patient moved his legs about with his hands. Sensi- 
bility was preserved except in the region of the pubis. The 
plantar reflexes were absent. Electrical reactions normal. 

The diagnosis was functional paralysis of the legs (previous 
gunshot injury of cauda equina). 

Treatment with psychotherapy met with prompt results; 
within a few days, the patient learned to move his legs and 
to walk with support, though making enormous efforts which 
threw the pulse up to about 160 and made the face congested. 
The bladder disturbance and the sacral anesthesia persisted. 



534 THE DIAGNOSIS OF SHELL-SHOCK 



Spinal concussion with spinal cord lesion: Ther- 
manesthesia and analgesia of right leg and side. 



Case 380. (Buzzard, December, 1916.) 

An officer was hit in the back by a shrapnel fragment, 
fell paralyzed, but after a few minutes was able to walk more 
than a mile to the dressing station. Eventually arriving in 
London, he had nothing to complain of except the wound, 
as the foreign body had been removed in France. The 
wound healed and the patient went to a convalescent home. 

However, when taking a bath he could not feel the tem- 
perature of the water with the right leg. Muscular power 
was perfect; reflexes normal; but the heat, cold and pain 
sense was lacking in the right leg and the right side of the 
body from the seventh costal cartilage downwards. 



One may make a wrong diagnosis of " Shell- 
shock." 



Case 381. (Buzzard, December, 1916.) 

In August, 19 1 5, an officer was blown many yards by a 
shell, lay unconscious a while, could find no bruises, and car- 
ried on for twenty-four hours. Then, finding legs unreliable, 
he reported sick and was sent home as "Shell-shock." He 
remained " Shell-shock" until February, 191 6, then being able 
to walk five or six miles on smooth ground. Going downstairs 
he took the step with left foot rather than with right, and the 
right was apt to turn in. The sense of position and move- 
ment in regard to the right foot proved to be faulty. He 
could not balance himself on the right foot, nor could he 
appreciate tuning fork vibrations as well on this foot as on 
the other. 

An X-ray examination showed a slight fracture, without 
deformity, in the left post-Rolandic region near the median 
line. His helmet had been bashed in at this point, and 
the bruised brain yielded symptoms even eight months later. 



THE DIAGNOSIS OF SHELL-SHOCK 535 



Retention of urine after shell-shock. 



Case 382. (Guillain and Barre, November, 191 7.) 

An infantryman underwent shell-shock December 19, 191 5, 
from the explosion of a torpedo nearby. He arrived at the 
ambulance, unable to speak, and next day had a confusional 
crisis of convulsions with contractures. He had not urinated 
since the accident, and two liters of clear urine were with- 
drawn by catheter; after which, the patient rested quietly 
and gradually regained consciousness. He was catheterized 
again in the evening and clear urine withdrawn. He re- 
mained unable to urinate spontaneously until December 25, 
and was catheterized accordingly. 

There was no motor, sensory, or reflex disorder in this 
patient. Lumbar puncture yielded a normal fluid; the 
pupils were normal, and the only appearance was that of a 
marked asthenia. 

Three months after his shell-shock, in March, 191 6, the 
soldier was once more examined and still complained of 
headache, weakness, and inability to walk more than four or 
five hundred meters without a certain trembling of the legs. 
The reflexes remained normal and no further bladder trouble 
had supervened. 

Re anuria, Babinski remarks that, in days of yore, hysteria 
was supposed to be able to produce anuria as well as albumi- 
nuria, and even such organic changes as vesicles of the skin, 
ulceration, hemorrhages in the skin or of the viscera, fever, 
and even gangrene. He remarks that of late years no single 
identifiable case of this sort proved to be hysterical, has been 
reported. This is aside, of course, from such superficial and 
quickly passing vasomotor disorders as erythema and derma- 
tographia. Anuria and albuminuria have consequently 
passed from the textbooks on hysteria, just as Babinski 
believes that hysterical edema and hysterical exaggeration 
of the reflexes are bound to pass. Hysteria cannot imitate 
everything; it cannot reproduce the characteristic phe- 
nomena of organic paralysis. 



536 THE DIAGNOSIS OF SHELL-SHOCK 



Retention of urine after shell-shock. 



Case 383. (Guillain and Barre, November 191 7.) 
An infantryman, 27, underwent shell-shock August 16, 
1 91 6, at four o'clock, from the nearby explosion of a big 
shell. He lost consciousness for a period of ten minutes, was 
sent to the regimental aid post, and twelve hours later 
brought to a hospital center, in a state of profound muscular 
weakness. He could not walk although he could make every 
movement of the legs. There was a marked diffuse cuta- 
neous hyperesthesia. The reflexes were normal; the pupils 
were unequal, the right myotic. The lumbar puncture 
yielded a clear fluid under normal pressure, but with an ex- 
cess of albumin. For three days, retention of urine was 
absolute, requiring the catheter. There was neither sugar 
nor albumin in the urine withdrawn. On the fourth day he 
was able to urinate spontaneously; the asthenia and other 
symptoms had disappeared in two or three weeks. 



Incontinence of urine after shell-shock and burial. 



Case 384. (Guillain and Barre, November, 19 17.) 
An infantryman was subject to shell explosion and burial 
May 10, 1917. He lost consciousness for a few hours and 
spat blood for two days. He was carried to an evacuation 
hospital and thence to the neurological center at Amiens. 
Incontinence day and night lasted from the period of shock 
up to May 29, when the patient was transferred again, to 
another hospital. The man had never, either in childhood 
or adult life, had incontinence. He showed a slight tendency 
to latero-pulsion toward the left. Puncture fluid normal. 

Guillain and Barre report but 12 cases of sphincter dis- 
order following shell-shock without external wound among 
hundreds of cases, and among 12 instances of sphincter dis- 
order there were but three of incontinence, of which the 
above is one example. Incontinence lasted longer in these 
cases than retention. Guillain and Barre are unable to 
assign a cause for the findings. 



THE DIAGNOSIS OF SHELL-SHOCK 537 



Struck in back by shell splinter: Crural mono- 
plegia; absence of plantar reflex. 



Case 385. (Paulian, February, 1915.) 

An infantryman, 20, was struck by a shell fragment in the 
small of the back while lying in the firing position, about 
2 p.m. August 22, 1 9 14, at Eth in Belgium. He felt as if he 
had been struck by the butt of a gun in the lumbar region. 
He was unable to get back with his comrades. His sack had 
been cut. He was without ammunition, and getting to a 
bridge he was able to jump a distance of about 8 meters. He 
fell and fainted. On coming to himself, his left side felt bad 
and he could not move his left leg. He dragged himself to 
the relief post which was being bombarded just as he ar- 
rived, and he got a bullet in the left frontal region. 

He was evacuated to another ambulance and decided to 
go back to France. Supported by his Lieutenant, he walked 
all night making about 35 kilometers on foot. He arrived 
at Charancy and got by train to Mont-Midi. On alighting, 
he could not walk. He said he was bent in two, and shuffled 
on in this position. 

The "bent-back " lasted about a month, when he began to 
stand up again. He passed through various hospitals and 
was evacuated to the Salpetriere. He then walked with the 
left leg in extension on the thigh and the foot in external 
rotation. He was hardly able to stand on either foot, and 
especially fell if he tried to stand on the left foot. He made 
no resistance to passive movements of the left lower extrem- 
ity. The reflexes were normal except that the left plantar 
reflex was abolished. On the right, the plantar reflex was 
normal, and an attempt to elicit this reflex was followed by 
strong defensive movements. There was a tactile, thermic, 
and pain anesthesia of the foot and leg as far up as the lower 
third of the thigh. Above this anesthesia, there was a zone 
of hypesthesia. Position sense was also abolished in this re- 
gion, and there was a bony hypesthesia likewise. A slight 
muscular atrophy (2 cm.) affected the lower leg and thigh. 



538 THE DIAGNOSIS OF SHELL-SHOCK 

There were no hereditary or acquired features of impor- 
tance in the case except that there had been at 14 a chorea for 
a year. In particular this man appears not to have been an 
emotional person. 

The point in the case is the abolition of the plantar reflex 
on the left side, in association with a functional paraplegia 
and hemianesthesia. 

Re plantar reflex modification in hysteria, Babinski believes 
that the same law which holds that hysteria is not in line to 
alter either the tendon reflexes or the pupil reflexes, is true for 
the skin reflexes. Dejerine brought forward three cases which 
appeared to him, however, to demonstrate absolutely that 
functional anesthesia might abolish or greatly diminish the 
skin reactions of the sole of the foot, that is, the plantar 
reflexes and movements of defense. Case 385 was alleged 
in support of Dejerine, as also were cases of Jeanselme and 
Huet, and of Sollier. Babinski's critique of Dejerine's cases 
ran to the effect that two of them showed contractures, and 
accordingly were not pure cases in which to demonstrate 
plantar reflexes or movements of defense. In the third case, 
Babinski at a meeting of the Neurological Society, himself 
obtained definite flexion of the little toes by stimulating the 
planta. According to Babinski, therefore, Dejerine's cases, 
far from proving that hysterical anesthesia could abolish 
the plantar cutaneous reflexes, proved that hysterical con- 
tracture might mask reflex movements. Hysterical contrac- 
ture, therefore, may be as important a factor to consider re 
reflexes as voluntary muscular contracture itself. As Ba- 
binski pointed out, many normal persons can keep the leg 
immobile when the sole is stimulated. Moreover, Babinski 
pointed out, many cases regarded as hysterical were actu- 
ally cases of a physiopathic or reflex nature which had 
actually undergone trauma. It will be noted that the above 
case of Paulian is just such a case of trauma. 



THE DIAGNOSIS OF SHELL-SHOCK 539 



Shell-shock; unconsciousness: Crural mono- 
plegia; sciatica (neural changes). 



Case 386. (Souques, February, 1915.) 

A reserve lieutenant, September, 19 14, was blown up by a 
shell and lost consciousness for an hour. On coming to, he 
felt pains in the loins, right thigh, knee and heel, and found 
himself unable to move the right leg at all. Urinary incon- 
tinence lasted three or four days. Violent pains lasted weeks, 
now and then actual crises (sleep only with hypnotics). 

The pains then passed off. The flaccid crural monoplegia 
lasted. There was a hydrarthrosis of the right knee and a 
sciatica (physical nerve changes?) and a crural monoplegia 
without trophic, electrical, reflex or vesico-rectal trouble. 
Lumbar puncture showed no lymphocytes or excess of al- 
bumin. It would, of course, be difficult to tell whether this 
case was hysteria or simulation. 

Re hysterical monoplegia, Babinski inquires whether a 
hysterical monoplegia can automatically appear as a result 
of emotion without any intellectual element whatever. Emo- 
tion produces sweat, diarrhea or erythema, without any 
intellectual intermediate. Can emotion — that is, emo- 
tional shock — produce a monoplegia in the same way as 
it produces an erythema? The narratives of patients might 
indicate that emotion can do such things. But according to 
Babinski there is no genuine case of monoplegia or para- 
plegia directly produced by emotional shock. One must be 
careful in this discussion not to confuse emotional shock and 
emotion of a gradual nature. Babinski wishes to define emo- 
tion as a violent affective change as a result of a [sudden 
mental shock upsetting physiologic or psychic balance dur- 
ing a usually brief period. As for the more gradual affective 
states or emotions, there is obviously so much of the imagi- 
native and intellectual compounded therewith, that plenty 
of opportunity exists for the production by suggestion of 
such ^phenomena as monoplegia, paraplegia, hemi-anesthesia. 

Re sciatica, see remarks above under Case 329. 



540 THE DIAGNOSIS OF SHELL-SHOCK 



Functional paraplegia and internal popliteal neu- 
ritis. 



Case 387. (Roussy, February, 1915.) 

A Zouave was taken out from under a trench shelter beam, 
the night of December 21, 1914, at Tracy-le-Mont. The 
beam had fallen upon eight men, killing one, and striking the 
Zouave in the hypogastrium. He was pulled out two hours 
later, unable to take a step. He was evacuated on his back, 
to Paris; stayed a month in the hospital at Croix- Rouge, 
bedfast. According to the patient, he was entirely anes- 
thetic in the legs. He went to Villejuif, January 22, with 
the diagnosis of spinal contusion and hemiplegia. He could 
then walk on crutches, leaning on the left leg. He felt a 
sharp pain at the level of the spinous process of the first 
lumbar vertebra and all along the sacrum. Spontaneous 
movements of the left leg were possible, but they were slow 
and weak. The hypesthesia rose to the navel. There was a 
suggestion of a cauda syndrome. The knee-jerks were nor- 
mal, but on the left side the Achilles jerk was absent. There 
was a partial R. D. in the posterior muscles of the left leg. 

The diagnosis was functional paraplegia plus left internal 
popliteal neuritis. The crutches were removed, he was iso- 
lated, and given motor reeducation. In a week he was able 
to walk alone with ease. 

Re popliteal nerve lesions, Athanassio-Benisty remarks that 
the external popliteal nerve of the leg resembles pathologi- 
cally the musculospiral nerve of the arm, whereas the in- 
ternal popliteal behaves like the median. The musculo- 
spiral nerve of the arm shows very variable and usually 
slight sensory changes. The median nerve more than any 
other nerve in the arm yields painful sensations during its 
recovery from section. 

Re differentiation of peripheral neuritis and hysterical 
paralysis, Babinski gives as signs peculiar to neuritis, and 
never found in hysterical paralysis, the following: (a) dimi- 
nution or loss of bone and tendon reflexes; (b) muscular 



THE DIAGNOSIS OF SHELL-SHOCK 54 1 

atrophy (except for slight amyotrophy exceptionally found 
in hysteria) ; (c) the reaction of degeneration (only of value 
after eight or ten days) ; (d) hypotonus ; (e) distribution 
characteristic of peripheral motor sensory and trophic 
disorder. 

Re diagnosis of organic paraplegia as against hysterical 
paraplegia, the latter is to be recognized chiefly by the ab- 
sence of the organic signs, as (a) alteration of tendon reflexes, 
(b) the Babinski sign (toe phenomenon), (c) exaggeration of 
defense reflexes (dorsal flexion of foot on sharp pinching of 
dorsum of foot or leg), (d) muscular atrophy with R. D., 
(e) sphincter disorder, (/) skin changes, such as decubitus. 



542 THE DIAGNOSIS OF SHELL-SHOCK 



Bullet in hip : Local " stupor " of leg. 



Case 388. (Sebileau, November, 1914.) 

A Moroccan sharpshooter, 20, was wounded September 
27, at Soissons. One bullet scratched the left thigh. A 
second entered below the anterosuperior iliac spine at least 
6 cm. outside the femoral artery and emerged above the 
ischiotrochanteric line, 2 cm. above and 4 cm. behind the 
upper extremity of the great trochanter, thus passing through 
the tensor of the fascia lata and without breaking a bone. 

There was a complete paralysis of the left leg. The man 
had to walk with a crutch and a cane, dragging the leg like a 
weight. There was no active or passive movement of thigh, 
lower leg and foot muscles, except that there was a slight 
tendency to abduction of the toes, from innervation of the 
dorsal interossei of the foot. The iliopsoas was also involved, 
as well as the gluteal and pelvic trochanteric muscles. There 
was a certain amount of muscular tone preserved, so that the 
bony elements of the skeleton were held together. The foot 
did not fall and the leg did not elongate, as it might have in a 
case of paralysis of the sciatic nerve. Electro-diagnosis 
showed an early reaction of degeneration according to one 
examiner, but Sebileau believes that there was no R. D. 
There was anesthesia of a large part of the leg, which stretched 
over the anterior and internal aspects of the thigh, covered 
the entire territory of obturator and crural nerves but did 
not stretch above the fold of the groin. The region of the 
femorocutaneous nerve was slightly sensitive and the pos- 
terior aspect of the thigh and buttock was sensitive. There 
was a slight sensation on the external aspect of the lower leg. 
Foot and toes were entirely insensitive. The anesthesia was 
for all forms of common sensation. No vasomotor, thermic 
or trophic disorder. The reflexes were all abolished, except 
for a tendency to cremasteric reflex. It is clear that these 
conditions cannot be simulated. Possibly they are hysteric 
and to be explained on the basis of a kind of autosuggestion 
or perhaps, according to Sebileau, the local and nervous 



THE DIAGNOSIS OF SHELL-SHOCK 543 

apparatus under the mechanical and caloric effects of the 
fragment had undergone a sort of local stupor. No large 
nerve could have been affected by the injury, according to 
the analysis made by Sebileau. 

Re stupor, see Case 253 of Tinel. Re such local "stupor" 
it may be noted that this case was published in 19 14, before 
Babinski 's larger publications on reflex disorders. As for 
the loss of cutaneous reflexes, Babinski remarks that immer- 
sion in hot water may cause the cutaneous reflexes in the 
so-called physiopathic cases to reappear for a time. He 
regards the loss of cutaneous reflexes in the physiopathic 
cases as due to a circulatory disturbance, and recalls the 
fact that compression by an Esmarch bandage can cause 
the tendon reflexes to vanish for a time, and can even cause 
pathologically excessive reflexes to disappear. The cuta- 
neous reflexes have also been caused to disappear by com- 
pression. 

According to Babinski, Sebileau's explanation that such 
matters as loss of reflexes could be explained by autosugges- 
tion is erroneous. 

Re muscular hypertonus in reflex cases, Babinski remarks 
that though it may be very pronounced, it is as a rule re- 
stricted in area. Re sensory disorders in reflex cases, pains 
are found (they were very slight ones in the present case) ; 
hypesthesia has also been found by Babinski. 



544 THE DIAGNOSIS OF SHELL-SHOCK 



Localized catalepsy: Hysterotraumatic. 



Case 389. (Sollier, January, 191 7.) 

An invalided soldier had been suffering for a year with 
marked atrophies and the right knee in extension. There 
had been a bullet wound of the upper third of the tibia, which 
did not affect the joint. There was a total anesthesia, both 
superficial and deep, which stopped sharply at the upper 
part of the thigh. At the time of the very first examination, 
this apparent ankylosis was reduced, to the great stupefac- 
tion of the patient. There was, however, a peculiar phe- 
nomenon in this subject. There was a localized catalepsy of 
the limb, which was able to preserve any desired attitude in 
which it was placed; and this attitude could be indefinitely 
prolonged, just as in cataleptic hysterics. Here, then, was a 
case of localized hystero-traumatism precisely imitating the 
classical hysteria of Charcot except for its localization. 

Re hysterotraumatism, Charcot developed ideas concern- 
ing trauma and localized hysteria in 1886, thereby over- 
throwing the ideas of Erichsen concerning the organic nature 
of " railway spine" and "railway brain" as developed twenty 
years before. In a case of local trauma such as the bullet- 
wound of Case 388, Babinski's explanation would be that the 
pain and inhibition of movement resulting from the bullet 
wound at the time of injury, formed the focus of a process of 
autosuggestion. According to Babinski's figure, the organic 
factor acts as a bait for the hysterical symptoms. Accord- 
ing to the Salpetriere experience, hysteria is incapable of 
producing a real superficial and deep anesthesia such as is 
mentioned for this case. For example, no hysterical patient 
in the Charcot clinic, according to Sicard, could undergo a 
scalpel operation without some general or local anesthetic. 
When, therefore, a true deep anesthesia occurs, Sicard's 
conception would be that the anesthesia is not a truly hysteri- 
cal one but belongs to the group of physiopathic phenomena. 



THE DIAGNOSIS OF SHELL-SHOCK 545 

L 



Contracture : Hysterotraumatic. 



Case 390. (Sollier, January, 1917.) 

A sailor, 41, got hygroma of the right knee in 191 5, was 
operated on in July, returned to his depot a month later, and 
thence to Vizille Urage by reason of contracture in extension 
of the right leg. It was thought he was simulating (since 
there was no muscular atrophy), and he was sent to the 
neurological center, where under anesthesia the joint was 
found free. This man developed, when the knee was bent, 
extraordinary cracklings in the joint, and he showed pain 
unequivocally, making a defensive movement, partly reflex, 
partly voluntary, when the leg was flexed beyond a certain 
point. There was 3.5 cm. atrophy in the thigh, a reflex 
atrophy due to the joint disorder. There were no other 
signs of hysterotraumatic contracture. 

According to Sollier, the diagnosis of hysterotraumatic 
contractures depends upon : first , a characteristic special atti- 
tude of the contractured limb; secondly, the participation of 
the antagonists as a group (global) ; thirdly, the superposition 
of sensory disorder upon motor disorder (Charcots law); 
fourthly, the segmentary topography of sensory disorder; 
fifthly, the extension of the contractured joint; sixthly, the 
persistence of the contracture in the same form, whether at 
rest or in attempted movements ; seventhly, muscular rigidity ; 
eighthly, normal tendon reflexes; ninthly, normal electrical 
reactions (though R. D. is hard to determine in muscles con- 
tracted to the maximum); tenthly, special reactions during 
attempts to reduce, such as pains, and equal and regular 
resistance to changed attitude, pseudoclonus in cases of foot 
contracture; eleventhly, immediate reproduction of the con- 
tracture after reduction under chloroform; twelfthly, co-ex- 
istence of various hysterical stigmata. 



546 THE DIAGNOSIS OF SHELL-SHOCK 



Crural monoplegia, tetanic. Recovery. 



Case 391. (Routier, 1915.) 

An ensign was wounded by a shell splinter in the right 
scapular region September 25, 1915. A large hematoma was 
drawn off and drains inserted. Antitetanic serum was given 
24 hours after the trauma. The wound looked well. The 
patient complained merely of the heaviness of his arm, and 
after September 27, the temperature fell to normal. Mag- 
nesium chloride solution was applied every other day, and 
progress was so good that evacuation was ordered. 

However, October 8, the patient suddenly began to com- 
plain of a sharp pain in the right thigh, which next day be- 
came intolerable and threw the muscles into a slight con- 
tracture, the adductors being extremely stiff. Headache 
developed in the course of the day, with slight stiffness of 
neck, exaggeration of reflexes in the right leg, and ankle 
clonus. Temperature: 37.6 morning, 38.5 evening. The 
patient was isolated and given chloral. 

October 10, paroxysmal crises of pain, more marked stiff 
neck, and lumbar stiffness appeared, with nervousness, 
photophobia, and hyperesthesia to noise. The wound seemed 
to be doing well. Chloral was given. 

Slight trismus developed October 1 1 . The tongue became 
dry and the patient drank little. The condition held and the 
same treatments were repeated up to October 15, when the 
temperature fell and the contractures and pains were dim- 
inished. The chloral was continued. There were still a few 
cramps in the neck. October 22, however, the patient was 
practically well. 

We are here dealing with an instance of local tetanus of 
monoplegic form, developing a fortnight after the wound 
(there is an early group developing, as a rule, from the fifth 
to the tenth day, and a group of later development, after 
the twentieth day; the interval in this case was of in- 
termediate duration). According to Courtois-Sufht and, 
Giroux, the differential diagnosis is not easy, since, besides 



THE DIAGNOSIS OF SHELL-SHOCK 547 

tetanus, must be considered tetany, spastic monoplegia of 
cerebral or spinal origin, partial hemiplegia, peripheral neu- 
ritis, contractures due to bone, joint, muscle or tendon 
lesions, strychnine intoxication and hysterical contractures. 
Three cases out of six described by Routier were fatal. 

Re differential diagnosis of tetanic conditions, see Cour- 
tois-Sufnt and Giroux in the Collection Horizon. The cases 
as a rule appear in subjects that have had serum treatment, 
and may occur in subjects in whom no trismus ever de- 
velops (the above case showed slight trismus). 

The recognition of localized tetanic contracture is based 
upon (a) the intensity of the contracture, which causes the 
limb to feel wooden (in one case the foot, leg, and thigh 
were welded to the pelvis like an iron bar) ; (b) paroxysmal 
contractions resembling those of tetanus, confined to one 
limb, and started by a variety of external causes, forming 
the principal symptom in the disease; (c) contracture of 
comparatively brief duration (hardly ever over two or three 
weeks). A slight fever may help in the differential diagnosis. 






548 THE DIAGNOSIS OF SHELL-SHOCK 



Wound of left leg : Local spasms, later contracture, 
and painful crises (these associated with suppura- 
tion), the whole treated as tetanic. 



Case 392. (Meriel, 1916.) 

An infantryman was wounded by shell fragments Septem- 
ber 28, 191 5, at Virginy and was given a first dressing an 
hour later and a second at the ambulance, where antitetanic 
injection was also made. October 3, the patient arrived at 
Foix, showing a superficial wound of the left frontal region, 
a penetrating wound of the upper third of the left thigh, and 
another in the lower third of the left lower leg. 

The evening of October 8, the man began to feel pain in 
the left leg, though the wounds looked well and there was 
no fever. October 9, sudden involuntary contractions of the 
left leg developed, and these increased in amplitude if the 
limb was touched. The other extremities were normal. 
Temperature 38.2; pulse 102. Restlessness at night. 

Next day 10 c.c. of antitetanic serum was administered and 
more on the nth, with chloral and isolation; but on the 
evening of the nth, with the contractions still completely 
localized to the left lower extremity, came an extremely 
painful crisis interfering with sleep and at last requiring 
morphine. Up to the 15th the antitetanic injections, chloral 
and morphine were continued, but on the 15th the contrac- 
tions were replaced in part by a contracture affecting the 
muscles of the posterior aspect of the thigh. In the mean- 
time, the patient howled with pain, especially in the night. 
Chloral and morphine were given. 

During the next five days the contractures and pains be- 
came still more violent, and on the 21st the antitetanic in- 
jections were begun once more and kept up through the 26th 
in 5 c.c. doses. 

The patient began to urinate in bed and to be delirious. 
The contractions now disappeared, but the contracture per- 
sisted. Antitetanic serum was given every other day from 
October 28 to November 2 ; ever}' third day from Novem- 



THE DIAGNOSIS OF SHELL-SHOCK 549 

ber 4 to November 19; every fourth day from November 2^ 
to December 3; and every fifth day from December 3 to 
December 17. The chloral was diminished from 15 to 5 
grams per diem and by the 20th of December all adminis- 
tration of chloral had ceased. The morphine was given up 
December 25. 

The tetanic symptoms of the left leg now gradually dimin- 
ished. The leg, which had been flexed at a right angle, 
began to extend little by little, and the toes, which had been 
strongly flexed, reassumed their normal position. The 
wounds suppurated freely during the tetanic crises, but then 
healed. In January the man could get up and walk, drag- 
ging his leg somewhat, and January 20 a complete recovery 
had been obtained. There was no hysteria in the history of 
this patient, although the man was subject to "professional " 
alcoholism, being carter for a wholesale wine dealer, drinking 
5 liters of wine a day 



550 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-shock by windage: Hysterical paraplegia, 
flaccid type, develops 10 days later, after strain, 
capture, privation, recapture. Paraplegia at first 
complete. Recovery by suggestion (one stance). 



Case 393. (Leri, February, 1915.) 

A corporal, 21, told how at Goselmind, during the Sarre- 
bourg retreat, August 20, 1914, a shell burst a meter behind 
him, flattening his knapsack, throwing him to the ground, 
blowing him forward (as he said, by the pressure of the 
air) seven or eight meters, leaving him stunned though con- 
scious for about twenty minutes. Uhlans fell upon him but 
did not trouble themselves further with him as he could 
not walk. He crawled along on elbows and knees about a 
kilometer and a half to some Frenchmen in a wood. He now 
found himself able to walk a whole day supported by two 
comrades, making about 12 kilometers. He got by carriage 
to Gerbeviller, but here fell again into the hands of Germans, 
who left him nine days in the corner of a barn without care. 
Gerbeviller was retaken, and he was evacuated to Bayon. 

He had now had for some time pains in the kidney region 
below the point struck, some difficulty in turning his head, 
and some numbness and jer kings in the legs; and the legs 
that had carried him 14 kilometers were unable to move at 
all, even in bed. It was only 8 days later that he could per- 
form the slightest movement, and two months followed be- 
fore he could go a few steps on crutches. December 14, 
three months and a half after his accident, — he was demon- 
strated as " spinal contusion." Upon examination, however, 
there were no reflex disorders, no sensory disorders, and the 
muscular weakness was equal in all parts of the lower ex- 
tremities and trunk. On crutches, he lunged the trunk for- 
ward, painfully dragging his legs one after the other, the 
right foot in external rotation, never passing the left foot, 
toes scraping ground, — a functional flaccid paraplegia, com- 
pletely dissolved by suggestion at a single sitting. 



THE DIAGNOSIS OF SHELL-SHOCK 55I 



Scalp wound; probably no loss of consciousness: 
Quadriparesis, later paraplegia; tremors; pro- 
found sensory disorders, some apparently hysteri- 
cal; cataleptic rigidity of (anesthetic) legs on 
passive movement. Diagnosis? 



Case 394. (Clarke, July, 191 6.) 

A soldier, 40, got a scalp wound but probably did not lose 
consciousness. However, when observed three months after 
the injury, though fat and well-looking, the patient could not 
stand or walk, and his hands and -arms were feeble. He 
complained of headache, insomnia and anorexia, and re- 
mained in a state of mental inertia. All efforts to read and 
write produced fatigue. Memory was bad both for remote 
and for recent events. He was able to feed himself slowly, 
execute a few movements of arms and hands, and raise his 
feet from the bed. Upon passive movement, there was a 
sort of spastic state, which did not amount to a true rigidity. 
Now and then a clonic spasm was induced by such passive 
movements. After the repetition of those few voluntary 
movements which were possible, the muscles passed into a 
flaccid condition. There was a tremor of a type called 
swooping; the tremor resembled that of Friedreich's dis- 
ease, such as is thought to occur in cases of marked loss of 
muscular sense. The deep reflexes were exaggerated. Con- 
centric narrowing of the visual fields was easily induced by 
testing them. There was a general slight dulness of percep- 
tion on sensory tests. There was astereognosis, and appar- 
ently an absolute loss of position sense. Movements of the 
large joints through an angle of 90 degrees were, however, 
vaguely recognized. Although the patient could not touch, 
for example, his left forefinger with his right, yet, if he had 
once seen the position of a limb and it was not moved, he 
could remember its position and touch it after some time. 
His localizing sense was from two to four inches out in the 
hands, the localization being generally of points proximal to 
the point tested. 



552 THE DIAGNOSIS OF SHELL-SHOCK 

Two months later the patient was somewhat less dull and 
apathetic. His memory had improved. He was able to 
read, and he was successfully making a rug; but the legs 
were worse, having become anesthetic to touch and pain. 
When the legs were placed in any position, they would as- 
sume a cataleptic rigidity, and remain rigidly fixed in any 
position for some time. The patient could sit up in bed. 
The muscles were well nourished and the electric reactions 
were normal. 

Re catatonic rigidity, see Case 389 (Sollier). 



THE DIAGNOSIS OF SHELL-SHOCK 



553 



Shell explosion; pitched in air: Spasmodic con- 
tractions of sartorii, persistent in sleep. 



Case 395. (Myers, January, 1916.) 

A private, 23, was admitted to a casualty clearing station 
and the next day told the examiner, Major Myers, that the 
Germans had been sending whizz-bangs and coal-boxes over, 
and the last he remembered was being on guard and then 
digging himself out of fallen sandbags. His comrades told 
him that he had been pitched in the air, but this he did not 
remember. He remembered running to the shell trench, 
but finding this " too hot," he returned to the firing trench, 
noticing on the way that he could not see well. He lay in 
the dug-out, flinching at each shell, and " trying to get into 
the smallest possible corner." He tried to do guard duty that 
night, but, when some one noticed involuntary spasmodic 
movements, he was ordered to go back to the dug-out, was 
helped to the regimental aid post by two men, and was sent 
to hospital. He had been in France eight months and had 
been shaken up somewhat four months before, when bombs 
threw dirt in his face. At that time, his hands and hand- 
writing had become tremulous, but he had not reported sick. 
He was depressed and wanted Major Myers to make him well. 
It seems that he had shrugged his shoulders and made leg 
movements, diving beneath the bedclothes, and bringing his 
knees to his chin. When Major Myers examined him, the 
leg movements were due solely " to strong periodic simul- 
taneous contractions of the two sartorius muscles, the rate 
of contraction of which varied from 60 to 70 per minute, 
increasing to 90 during the excitement of examination." 
There were special changes of sensibility in the right leg and 
arm and right side of the face and chest, not involving the 
abdomen. The patellar reflex was exaggerated; plantar re- 
flexes could not be obtained. The legs were tremulous, 
especially when the patient lifted them, whereas the hands and 
tongue were only faintly tremulous. 



554 THE DIAGNOSIS OF SHELL-SHOCK 

Under light hypnosis, events in the amnestic period were 
recalled, and details as to the shell's direction, process of 
lifting up, and fall. Under deeper hypnosis, the sartorius 
contractions diminished but did not disappear. Appro- 
priate suggestion was made, and upon arousal from hypnosis, 
the movements ceased, the headache disappeared, memory 
was recovered, and the unilateral disturbances of sensibility 
had vanished. 

As to the possibility of malingering in this case, Major 
Myers calls attention to the disorders of sensibility which he 
believes could hardly have been simulated, to the persistence 
of spasmodic movements during sleep, to their confinement to 
the sartorii, and to the spastic condition of legs, such that 
when the thighs were passively raised the knees remained 
extended. 

Re persistence of hysterical phenomena in sleep,' Ballet 
felt that he could prove that some hysterical contractures 
persisted during sleep, and Sollier has written a special 
article to the same effect. Ballet's case had a contracture 
developing after an operation on the first metacarpal bone. 
The contracture which followed would be then probably, 
upon Babinski 's analysis, a reflex contracture and not a 
hysterical one. Duvernay, Sicard, and Babinski himself 
have noted the persistence of reflex contractures during 
sleep, to say nothing of their persistence under an advanced 
stage of chloroform narcosis. In fact, these reflex contrac- 
tures are exactly as fixed and persistent as contractures of 
clearly organic origin. It is probable that Babinski would 
define Myers' case (395) as a physiopathic one; yet against 
this diagnosis would be the disappearance of the movements 
after hypnosis. As against hysteria, it will be noted that 
the patellar reflex was exaggerated, and that the plantar 
reflexes could not be obtained. 



THE DIAGNOSIS OF SHELL-SHOCK 555 



Shell-shock: Brown-S6quard syndrome, hemato- 
myelic ? 



Case 396. (Ballet, August, 191 5.) 

A soldier, 24, went to the front November 12, 19 14, and 
June 1, 191 5, had a shell burst near him in the trench, on the 
occasion of which he felt a violent shock, as if a blow in the 
kidneys. He felt suddenly paralyzed in both legs. He was 
crouching at the time of the shell burst. His legs felt dead, 
and he had such violent pain in the thorax as to make 
breathing difficult. He was carried to a shelter. After a 
few hours, the left leg began to move again. 

He was carried to the ambulance, remaining there five days, 
unable to walk, though able to move and turn in bed, 
slightly constipated, with persistent pains in back. He was 
then carried to Auxiliary Hospital 231, at Paris, and a 
bullet ( ! ) was found superficially lodged in the region of the 
left scapula. Neither patient nor physicians had hitherto 
observed the bullet, which could have had nothing to do with 
any spinal lesion. 

The pains, in the course of a month, grew less, and at the 
end of two or three weeks he began to walk and was sent to 
the psychoneurosis service at Ville-Evrard, July 10. He 
then complained of pain in the right thorax, especially on 
movement or after sitting up some time. He could hardly 
bring himself to the sitting posture from the bed, and found 
difficulty in raising the right leg therefrom. In walking, the 
right leg was dragged behind. The reflexes were increased on 
the right side. There was ankle clonus without Babinski 
sign. Anesthesia to touch over the whole of the left leg. 
Anesthesia to pin prick and temperature as far as the um- 
bilicus. Cold was not felt on the left side. 

The water of a bath seemed lukewarm on the left side and 
warm on the right. The left side of the scrotum and the left 
half of the penis showed the same disorder of sensibility. 
There was a zone of hypesthesia on the right side of the thorax 
in the region of the lower ribs. The patient compared his 



556 THE DIAGNOSIS OF SHELL-SHOCK 

sensations while at rest and without contact to a sensation of 
painful pressure occurring intermittently, or rather in par- 
oxysms, not advancing beyond the median line of the back. 
Here was a question of Brown- Sequard syndrome, probably 
due to a slight hematomyelia, but associated with no ex- 
ternal lesion or any injury to the vertebral column. 

Re Brown-Sequard's syndrome, see Athanassio-Benisty 
with respect to spinal cord symptoms associated with lesions 
of the brachial plexus. It appears that the combination of 
spinal cord and brachial plexus injury is not uncommon. 
Note in this case that a bullet was found in the left scapula 
region. According to Ballet, this bullet could have had 
nothing to do with a spinal lesion. 



THE DIAGNOSIS OF SHELL-SHOCK 557 



Violence to back : Dysbasia. Antebellum injury. 



Case 397. (Smyly, April, 191 7.) 

A man (also injured in 1906 by the fall of a heavy weight 
on his back) went to France in 1914 as a soldier, and eight 
months later was hurled into a shell hole so that his back 
struck the edge. He was rendered unconscious. Upon re- 
covery of consciousness, the right leg was found to be swollen, 
and there were severe pains in the legs and back. 

Upon return home the patient went from one hospital to 
another, for the most part unable to walk, suffering from 
agonizing pain in head and eyes. Insomnia and waking 
dreams. 

He was able to bring himself to an upright position and to 
rush a few steps. He has now acquired considerable control 
of the feet by the aid of crutches. Insomnia persisted. 



Dysbasia: Psychogenic (cerebellar nucleus (?)) 



Case 398. (Cassirer, February, 191 6.) 

On March 9, 1915, a shell wounded a man slightly, and 
burned off some of the hair of his head. He was uncon- 
scious two days, and on waking vomited for a time. Shortly 
after the injury difficulties in standing and walking set in, 
with headache, noises in the left ear, difficulty in the intake of 
ideas, excitability, and poor memory. Then, slight improve- 
ment. About the middle of June he was no longer closely 
confined to bed and could take a few steps with two canes; 
but the gait was still unsteady and the left leg tended to make 
abnormal-looking movements. There was nystagmus, rapid, 
though constant, on looking to the left, — more in the left 
eye ; and nystagmus on looking to the right, — more in the 
right eye. Adiadochokinesis absent. Vestibular nerve some- 
what excitable. Deviation outward in finger- pointing test. 

According to Cassirer, this case is one largely of psychogenic 
origin, with possibly an organic cerebellar nucleus. The knee- 
jerks absent (even up to March 31). W. R. negative. 



55^ THE DIAGNOSIS OF SHELL-SHOCK 



Shell-shock; unconsciousness: Dysbasia, in part 
hysterical, in part organic (?). 



Case 399. (Hurst, May, 1915.) 

A private, 29, was knocked over by a shell explosion 
December, 191 4. He was unconscious two days, found that 
he could not move either right arm or left leg, got some 
power back shortly, but, if he tried to stand, experienced in- 
voluntary violent movements in the left leg. 

April 1, 1 91 5, response to questions was slow and speech 
slow. The right arm and grip were weak. If the left hand 
was clenched, there was an associated movement of the right 
hand; but on clenching the right hand, no associated move- 
ment was produced in the left. The musculature was equal 
on the two sides, and the tendon reflexes of the arms were 
brisk and equal. Light tactile stimuli were hard to localize. 
Movements of the left leg were somewhat weak, though the 
musculature was equal on the two sides. The knee-jerks 
were brisk, the left slightly brisker. Sometimes a well- 
marked ankle clonus could be obtained on the left side, but 
sometimes not. The plantar reflex was constantly flexor. 
Babinski's second sign (combined flexion of thigh and pelvis) 
was well marked on the left side. 

On attempts to walk, the left leg would move rapidly from 
side to side, round the point of contact of toes with ground. 
When a step forward was taken with the right leg, the left 
one dragged, and made irregular movements. 

This gait seemed obviously hysterical. The patient was 
kept in hospital for a month. He was very easily hypno- 
tizable, but even in deep hypnosis leg movements could not 
be controlled when he was told to walk. The first whiff of 
ether hypnotized but did not cure him. 

On the whole, upon review, Hurst believes that there may 
have been organic brain changes, which (a) the associated 
movement of the paralyzed hand when the normal hand was 
contracting, (b) the slightly increased left knee-jerk, (c) tend- 
ency to ankle-clonus, and (d) Babinski's second sign, may 
show. 



THE DIAGNOSIS OF SHELL-SHOCK 559 



Peculiar walking tic, 



Case 400. (Chavigny, April, 191 7.) 

A soldier was found with a peculiar walking tic. He would 
rest a good deal longer on the left leg than on the right. He 
would make a sudden movement of the right leg forward, as 
if on a spring. At the same time, the man's head would give 
a violent movement to the right just as the right leg was 
receiving the weight of the body. The idea of this move- 
ment seemed to be that the center of gravity would be shifted 
and the work of the right leg would be relieved. This peculiar 
walk was naturally very slow. If the walk was slowed down, 
it became quite normal. There was no pain at the basis of 
this walk. If the man hopped, he hopped no more painfully 
on the right leg, nor with greater difficulty, than upon the 
left. 

This man was guilty of desertion in the face of the enemy, 
and of desertion in the interior in time of war. He said he 
could not walk well and that he needed to take care of himself 
at his mother's house, as he was not considered sick in his 
regiment. He had been wounded with two bullets, September 
28, 1 9 14, which struck him on the internal aspects of the 
knees. He was treated in hospital from October to the end 
of November, 19 14; was held at the depot of his regiment 
from December to August, 191 5. He was then put in hospital 
a month, and returned to his depot for three more months. 
He was examined by three physicians in August, 191 5, and the 
commission decided that he was fit for service, and a simu- 
lator. 

Thorough examination, including electrical and X-ray 
examinations, showed no lesion. Chavigny observed the 
patient for a long time, from the 21st of November, 191 6, to 
January 5, 191 7. Shells dropped near the hospital, Decem- 
ber 2, and, following orders, the patients were taken into a 
vaulted cellar, and they ran thither very rapidly; but this 
patient could not hurry. He walked slowly, with the same 
tic. Surely the tic would be rather a difficult one to imagine, 



56O THE DIAGNOSIS OF SHELL-SHOCK 

and a somewhat more probable set of symptoms would 
ordinarily be chosen. The man has not the unstable nature 
of the ordinary victim of tic. On the contrary, he has rather 
the invincible obstinacy of a hysterotraumatic. On being 
shown that he could walk properly without these "para" 
movements, he would reply, " I can't do anything else," and 
he shook his head upon being told that he could be cured. 

Reeducation of his anesthetic areas (there was a zone of 
diminution in sensibility to pin-prick in the knee region, and 
a complete anesthesia of the sole of the foot, with abolition of 
the plantar reflex), reeducation by appropriate gymnastics, 
and mental reeducation, might be attempted in a special neu- 
rological hospital. 

Re disorders of gait, Laignel-Lavastine and Courbon divide 
functional gait disorders into three groups: (a) ~A group 
called dynamogenic; (b) an inhibitory group; and (c) a 
group showing both forms of disorder. 

Roussy and Lhermitte have attempted to divide the gait 
disorders into two groups: (a) A group termed by them 
basophobic, in which there is a marked psychogenic and 
emotional basis; and (b) a dysbasic group, the basis of 
which is suggestion rather than emotion. Following is a 
skeleton of their classification: 

1. Astasia-abasia and dysbasia group. 

Astasia- abasia Choreiform dysbasia. 

Pseudo tabetic dysbasia. Knock-kneed gait. 

Pseudo polyneuritic dysbasia. Walking as if on sticky 
Tight-rope walker's gait. surface. 

Scrubber's gait. Bather's gait. 

2. Stasobasophobia group. 

3. Habit limping. 



THE DIAGNOSIS OF SHELL-SHOCK 56 1 



Mine explosion ; unconsciousness : Camptocormia. 
Hospital rounder twenty months (bedfast five 
months) without complete neurological examination. 
Cure by persuasive electrotherapy in one hour. 



Case 401. (Marie, Meige, Behagne, February, 1917; 
Souques and Megevand, February, 191 7.) 

A man became a hospital rounder to all points of the com- 
pass in France during a period of twenty months, with such 
diagnoses as myelopathic disorder, complex spinal trouble, 
ataxic phenomena. 

As a matter of fact he was a camptocormic : trunk bent, 
knees semi-flexed, legs in external rotation. He used two 
canes in locomotion, made a bowing movement with each 
20 cm. step, then another bowing movement, and another 
little step with the other foot. Made to lie down, his legs 
would elongate, the right completely but the left with some 
difficulty, the feet going into hyperextension, with the big 
toe raised, others flexed ; the feet externally rotating, plantae 
turned in. In horizontal decubitus, there was only slight 
lumbar discomfort, but the legs stiffened and gave quick 
convulsive jerks. Taking the posture several times in suc- 
cession would diminish these phenomena. Kneeling, he 
could bring his heels within 10 cm. of the buttock, whereas 
in spontaneous flexion of the leg on the thigh, the knee re- 
mained a distance of 40 cm. from the buttock. 

A complete examination showed no joint disorder or any 
diminution in muscular strength, or any reflex disorder ex- 
cept that all the tendon reflexes were rather powerful. There 
was a question of possible X-ray demonstration of lesions and 
ankylosis of the fourth and fifth lumbar vertebrae, and there 
was a question of some incontinence of urine. On the basis 
of these phenomena apparently, this camptocormic patient 
had been saddled with the diagnosis of myelopathic and 
ataxic disorder for a period of 16 months. A neurologist was 
at last consulted, and on his advice, it proved possible to get 
the patient evacuated to a neurological center in a period of 



562 THE DIAGNOSIS OF SHELL-SHOCK 

four months. Facts of this species are unfortunately still too 
common, state Marie, Meige and Behagne, February I, 1917, 
despite the remarkable and rapid cures obtained in campto- 
cormia by Souques. In point of fact, no complete neuro- 
logical examination had been performed upon this man 
during a period of 20 months. 

This particular patient was given to Souques for treatment 
(Souques and Megevand). His cure was completed by per- 
suasive electrotherapy, in an hour. 

It appears that the man was buried in a mine explosion, 
June 5, 1 91 5, lost consciousness and came to twenty hours 
later, able to rise and take a few steps, but bent in two 
with a sharp dorsolumbar pain. The pain grew more violent 
and generalized during the next few days, and he began to 
lose all power in his legs, so that he could walk with the 
greatest difficulty. He was practically bedfast for five 
months. He then tried to rise and walk, but suffered so 
much that he could not get up except in a camptocormic 
position. It was in fact only January 23, 191 7, at the 
Salpetriere, that the diagnosis of camptocormia was made. 
The man complained of pains at the lower dorsal and lumbar 
regions of the spinal column with slight irradiation sidewise. 
The following diagnoses had been made: 

June 8, 1 91 5. Severe contusion of chest and back. 

July 9, 191 5. Multiple contusions, commotio spinalis; 
lesions and ankylosis of the 4th and 5th lumbar vertebrae 
(X-ray examination). 

Sept. 3, 1 91 6. Lumbar intervertebral arthritis with com- 
pression of roots. 

Nov. 4, 191 6. Myelopathic disorder. 

Dec. 5, 1 91 6. Old complex spinal disorder. 

Souques remarks that these diagnoses show that knowledge 
about camptocormia has not penetrated into most of the 
sanitary formations (19 17). 



THE DIAGNOSIS OF SHELL-SHOCK 563 



Astasia-Abasia. 



Case 402. (Guillain and Barre, January, 191 6.) 

A soldier was evacuated to the 6th Army neurological 
center for paraplegia with tremor. He had been in various 
hospitals for a period of a year. The tendon reflexes of the 
arms appeared increased; there was a suspicion of patellar 
clonus and of foot clonus, and it had been proposed to invalid 
the man for spastic paralysis. In point of fact, the man was 
suffering from an epileptoid trepidation of the foot and of the 
patella. When he was lying down, his motor disorders prac- 
tically passed away, though they had been very marked when 
he tried to stand upright or to walk. He had much trouble 
in walking, but could readily stand for some time on one leg. 

The man was forthwith treated by persuasive methods. 
It is important to find out the organic lesion which in all 
probability served as a starting point for the functional 
disease, and important to remove or abolish this lesion how- 
ever minute if a complete and lasting cure is to be obtained. 

Re astasia-abasia, writers have remarked that it is one of 
the commonest hysterical syndromes in the war, though 
somewhat rare in its complete form. Roussy and Lher- 
mitte state that it usually follows the explosion of a large 
calibre projectile and has a rapid onset. It is often an iso- 
lated phenomenon, without emotional or other Shell-shock 
complications. The victim has been thrown to the ground 
and rolled into a trench or hollow. Sometimes the victim 
gets back to the first-aid post, only to find himself on arrival 
at the ambulance wholly unable to walk. The legs, however, 
are drawn along inertly, as in paraplegia, or a pronounced 
contracture interferes with walking. 

Astasia-abasia is classified with hysteria major, hysterical 
hemiplegia, hysterotraumatic brachial monoplegia, glosso- 
labial hemispasm, hysterical mutism, and rhythmic chorea, 
as so characteristic that differential diagnosis is superfluous. 
According to Babinski, no functional spasm and no organic 
disease can reproduce hysterical astasia-abasia. 



564 THE DIAGNOSIS OF SHELL-SHOCK 



Multiple shell wounds, with persistent slight sup- 
puration of thigh: Abdominothoracic contracture, 
tetanic, four months after original injury. 



Case 403. (Marie, 1916.) 

A soldier, 31, was wounded in the left arm January, 1915, 
and received 10 c.c. antitetanic serum; was wounded again 
July 10 in the face, scalp, upper part of the thorax, left arm 
and left leg by shell fragments, and again received, two days 
later, 10 c.c. antitetanic serum. July 13, at the ophthal- 
mological center at Rouen the left eye was enucleated on 
account of a shell wound, and four days later a fragment was 
removed from a phlegmon of the forearm. Later a number 
of operations were made for blepharoplasty. The wounds 
all healed well except for an apparently insignificant, small 
suppuration of the thigh. November 10, four months after 
the shell wounds, while apparently in perfect health, the man 
began to complain of lancinating, intermittent pains in the 
abdomen, thorax and lumbar region. With these pains was 
associated a persistent abdominolumbar contracture. 

On the suspicion of an abdominal form of local tetanus, 
chloral was given ; but the condition grew worse. The sudden 
contractions spread from the waist to the feet, from November 
20 onward, and were felt by the patient as electric shocks. 
The arms were not affected. Trouble with breathing super- 
vened on the night of December 3. Sometimes there were 
respiratory pauses for as long as 15 seconds, followed by a 
slight polypnea. December 6 the man presented an intense 
contracture of the lower part of the trunk. The slightly 
retracted abdominal wall was of marbly hardness, but quite 
painless. Analgesic muscular rigidity took the place of the 
former crises of pain. The dorsolumbar contracture was so 
marked as to make an appreciable hollow in the back. The 
patient could pick up an object from the ground only by 
flexing his knees to the maximum, as the trunk could not be 
flexed. There was a very slight trismus, but he could open 
his mouth, drink, eat and talk without difficulty. There was 



THE DIAGNOSIS OF SHELL-SHOCK 565 

no trace of neck stiffness or of Kernig's sign. The tendon 
reflexes, normal in the arms, were exaggerated in the lower 
extremities, especially on the left (wounded) side. The skin 
reflexes were also more marked on the left side, especially the 
reflex of the tensor of the fascia lata. There was no longer 
any evidence of suppuration of the wound of the left thigh, 
which had been dried up for a fortnight. The pulse was 
somewhat exaggerated (92) and there was a general hyper- 
idrosis, especially of the face. 

Forty c.c. antitetanic serum were given without reaction, 
and 4 grams of chloral; five days later, 30 c.c. more serum. 
After ten days the abdomen remained hard, though there was 
a trifling improvement of the lumbar contracture. There 
were no longer any spasmodic crises or respiratory disturb- 
ances. There was a slight serous exudation from the wound. 
X-ray showed a small shell fragment 6 cm. below the orifice 
of the wound. 

The third injection was given December 27 to prevent 
mobilization of the bacilli at operation, and on the 28th, the 
projectile was removed under local anesthesia from a small, 
walled-off, old pus pocket, from which were cultivated bacillus 
perfringens and other organisms. 

December 31 a distinct improvement set in and January 
13 there was little or no trace of previous disease, except that 
testing the plantar cutaneous reflex on the left side produced 
an exaggerated contraction of the tensor of the fascia lata. 
February 15 he was reexamined and found quite normal. 

This, case of tetanus limited to the abdominothoracic 
muscles (except for a very mild contracture of the masti- 
cators) had as its locus of origin, doubtless, a wound of the 
thigh from which the toxin rose along branches of the lum- 
bar plexus to impregnate the corresponding level of the spinal 
cord. Although there was no stiffness of the wounded leg, 
yet there was an exaggeration of the tendon reflexes thereof. 
The first phase of painful contractures and spasms with 
respiratory disorder was succeeded by an analgesic phase of 
characteristically tetanic rigidity. The nonfebrile nature of 
the disease and the preservation of good general health are 
worth noting. 



566 THE DIAGNOSIS OF SHELL-SHOCK 



Shoulder blade unslung in knock-down by shell 
splinter: Hysterical (!) paralysis of arm with 
anesthesia. Recovery by electricity, massage, and 
reeducation (dislocation remaining). 



Case 404. (Walther, December, 1914.) 

A soldier was struck September 2J, near Berry au Bac, by 
a shell fragment in the right scapular region and was thrown, 
according to his story, 15 meters. Upon entrance at Val-de- 
Grace, October 13, the shoulder-girdle was found intact. 
There was a very painful point in the spinous process of the 
scapula, suggesting a fracture; but the bone was proved in- 
tact on X-ray. The scapula was very mobile, as if unslung 
from the thorax. The arm was paralyzed. On raising the 
arm the scapula followed its movements and detached itself 
completely from the thorax, dislocating upwards with lively 
pain. The fingers could be pushed under the anterior surface 
of the scapula, and its internal border proved to be entirely 
free of attachment. Pressure along this internal border was 
very painful. It seems as if there had been a tearing of the 
rhomboid and serratus magnus muscles and probably a part 
of the latissimus dorsi under the influence of the violent 
shock conveyed by the shell fragment, which had pushed the 
scapula forward and upward without injuring the skin. 

There was also a complete paralysis of sensation. Paraly- 
sis of motion was complete except for the extensor longus of 
the thumb. This motor paralysis had come on progres- 
sively three days after the accident. A radicular paralysis 
from an evulsion of the plexus was suspected. 

Babinski, however, made the diagnosis of psychic paralysis, 
finding the muscles reacting perfectly to percussion. After 
a few electric tests with the faradic current voluntary move- 
ments were obtained in all the muscles of the arm and hand. 

Treatment was then continued by electricity, massage and 
reeducation, so that all movements soon regained strength. 
The patient can now himself, by raising his arm, still produce 
his dislocation, which still provokes a lively pain. 



THE DIAGNOSIS OF SHELL-SHOCK 567 



Gunshot wound of left forearm: PARALYSIS of 
the arm gradually INCREASING IN DEGREE and 
extent and associated with pains and anesthesias. 



Case 405. (Oppenheim, July, 1915.) 

A reservist sustained, October 2, 1914, a gunshot wound 
of the left forearm from a distance of about 1400 meters. He 
fainted, lost much blood, and was treated surgically, October 
7, in hospital (at this time no complete paralysis of the arm). 

In November, however, an incomplete paralysis at first 
developed. November 12, the patient was able to flex his 
thumb but showed some anesthesia. 

Transferred to nerve hospital in December, the patient 
said that at the first change of dressings, October 10, he had 
not been able to move his arm, and said that pains and pares- 
thesia had existed in the arm ever since the injury. There was 
still some evidence of suppuration at the exit orifice of the 
bullet. The left arm was now completely paralyzed and 
atonic, and hung down in walking, without swinging. The 
supinator phenomenon, though present on the right side, was 
absent on the left. The triceps reflex was present. The 
shoulder acted like a flail joint. On passive elevation of the 
left arm, the deltoid seemed to contract slightly at first ; later 
it failed to contract. Fibrillary tremor of the left thumb. 

Suggestive therapy was unsuccessful. There was an an- 
esthesia of the left arm and the left trunk. The disorder 
diminished proximally, being most severe in the hand and 
the arm. The legs were normal. The electrical irritability 
of the left arm was only slightly diminished. There was a 
well-marked hypertrichosis of the left forearm, the skin of 
which was slightly purple and discolored. The patient him- 
self made an attempt to burn his arm with a lighted cigar, to 
see if he could feel the pain. He showed the scar but had 
felt nothing. The pectoralis major muscle did not contract. 
If the left arm was started actively swinging, it kept on 
swinging inertly. The left hand showed hyperidrosis. The 
small hand muscles were emaciated but electrically normal.] 



568 THE DIAGNOSIS OF SHELL-SHOCK 



Glass wound of wrist: Differential glove anes- 
thesias (cold to mid forearm, pain somewhat higher, 
touch as far as elbow). 



Case 406. (Romner, March, 191 5.) 

A German soldier, 37, wounded his right wrist in the glass 
of a door. The hand was put up six weeks long with very 
few changes of the bandage on account of suppuration, and 
he noticed that the arm was getting weaker and weaker, that 
he was losing feeling in it, and that it was beginning to sweat 
a good deal, so that now and then drops of sweat would 
stream off. The right hand was found markedly congested 
and 1.5 cm. larger in circumference. The fingers and hand 
were especially weak. There was a marked tremor of the arm. 
Electric excitability normal. The sensory disorder was in 
glove form. Hypesthesia to touch reached the elbow, anal- 
gesia to a point three fingers' breadth below the elbow, and 
anesthesia to cold to a point two fingers' breadth still lower, 
a sort of stepwise dissociation of sensibility resembling what 
is found in spinal lesions. The case was presented as one of 
local traumatic hysteria. 

Re hysterical anesthesia, the rule is that it obeys no definite 
rule; that is, it may be a hemianesthesia, a segmentary, an 
isolated, or even a pseudo-peripheral anesthesia. It is a ques- 
tion whether Babinski would attempt to explain Romner 's 
case on the basis of medical suggestion, hetero-suggestion, 
or autosuggestion. 

Myers has had a few instances in which anesthesia spread 
gradually, and in which analgesia increased after its onset. 

Re reeducation of cutaneous sensations, Chavigny recon> 
mends the faradic current in successive applications, mark- 
ing the extent of the zone of anesthesia with ink upon the 
skin. Each time the current is applied, the inked limits of 
the area are lessened. By this form of suggestion, not only 
does the anesthesia disappear, but very often the accom- 
panying paralysis also. 



THE DIAGNOSIS OF SHELL-SHOCK 569 



Hysterical contracture, edema'and vasomotor disorder. 



Case 407. (Ballet, July, 1915.) 

For some unknown reason, a soldier developed a contrac- 
ture of the right upper and lower extremities at a time when 
a basin of water was offered to him for toilet purposes. Three 
days later, this contracture disappeared in the leg but per- 
sisted in the arm at the radiocarpal joint and in the finger 
joints. There was also an anesthesia to touch and pain and 
temperature which ran up the arm to the shoulder. The ten- 
don reflexes were normal. On the whole, there seemed to be 
no doubt that the case was one of hysterical arm contracture. 
Associated with this contracture was a white edema of the 
hand. On account of the chances of simulation, the hand 
was done up and sealed in such wise that the seals would have 
been broken if the splint had been lifted down during the 
night. The bandage was in place from June 25 to June 29. 
Upon its removal, there was no edema, but the contracture 
was still there. The arm was put up upon a cushion so that 
the hand would drain to the forearm. The edema was found 
capable of returning when the hand was placed below the 
level of the shoulder, disappearing when the hand was raised. 
The contractured hand was warmer than its fellow. Accord- 
ing] to Ballet, we here have an anesthetic instance of con- 
tracture associated with edema and vasomotor disorder. 

Re edema, Babinski states that no case of hysterical edema 
has stood the test of scientific critique. Sometimes a case 
turns out one of tuberculous synovitis. Sometimes the 
patient is shown artificially to have brought about the edema. 
The hysterical "blue edema" of Charcot has not been proved 
to exist. Some during the war have been found due to vol- 
untary constriction. Some of these constriction edemas even 
become relatively permanent. Babinski regards the above 
case of Ballet, as well as cases of Lebar and of Raynaud, as 
not true cases. Raynaud's case was probably vascular. 

Re vasomotor disorders in Ballet's case, the Babinski school, 
of course, holds that hysteria cannot cause such disorders. 



i 



570 THE DIAGNOSIS OF SHELL-SHOCK 



Hemiparesis with syringomyelic dissociation of 
sensations. 



Case 408. (Ravaut, August, 1915.) 

A road-laborer, 42, in the 268th Infantry, had a bomb 
burst about a meter away, March 4, 191 5. Three men near- 
by were killed, and two wounded. The laborer himself 
was turned over, covered with earth, and stunned. He could 
hardly get up. He was carried to shelter and found para- 
lyzed on the left side, and unable to speak. 

Next day, he was carried to the ambulance, and hemian- 
esthesia was found to exist in addition to the hemiplegia. He 
could now speak with some difficulty and stammered. Vision 
and hearing were also impaired on the left side. Reflexes 
weak; no sign of wound. There was a convulsive crisis of 
some sort during the day, and afterwards the man complained 
of a violent headache, whereupon a lumbar puncture showed 
a clear fluid and a marked excess of albumin by the heat test. 

The following day, March 6, the patient had much im- 
proved; his hemiplegia was less marked and the arm paraly- 
sis had almost entirely disappeared. He still stammered. 

Upon the next day, vision and hearing were normal, and 
the sensation was practically normal. A second lumbar 
puncture, March 8, showed a diminution in the amount of 
albumin, although it was still supernormal. 

March 9, leg contractured in extension; stammering. 

March 12, there was no evidence of disease. March 13, 
albumin was very slightly increased over the normal in the 
puncture fluid. March 16, there was a slight trace only of 
weakness in the left leg. The urine was throughout normal. 
The patient wrote Bavo April 12, and May 7 he was well but 
still felt heaviness and pulling sensations. 

July 15 it was reported at Tours that he was not yet well, 
presenting a left-sided hemiparesis, especially in the leg, 
with a syringomyelic dissociation of sensations, with atrophy 
of the quadriceps and diminution of reflexes on the left side. 
The patient had had a hematomyelia (Laignel-Lavastine). 



THE DIAGNOSIS OF SHELL-SHOCK 



571 



Brachial monoplegia, tetanic. 



Case 409. (Routier, 1915.) 

A soldier sustained a penetrating wound of the back of the 
thorax on the left side and received an injection of antitetanic 
serum. A few days later, May 18, 1915, he came on hospital 
service very sick, with high temperature and marked sup- 
puration. The next day he had an anxious facies, tempera- 
ture o.f 40 degrees, and sharp pains in the left arm. This 
arm May 21 was still very painful and then began to make 
involuntary movements in the shape of incessant clonic 
contractions. The forearm would suddenly flex upon the 
upper arm, and the upper arm itself would violently push it- 
self forward and outward. Meantime, the wrist and fingers 
were not involved in the contractions. The movements were 
continuous, but paroxysmally increased in extent. 

Babinski, called in consultation, confirmed the diagnosis of 
an anomalous form of tetanus. Next day trismus, pleuros- 
thotonos, and stiff neck developed. Antitetanic serum and 
chloral had been given from the beginning, with morphine 
at night. The patient, however, died with asphyxia June 3. 

Re brachial monoplegia, the hysterotraumatic form first 
observed by Charcot has an anesthesia with the shoulder of 
mutton distribution, slightly affecting the thorax in front 
and behind, in addition to the paralysis. 



572 THE DIAGNOSIS OF SHELL-SHOCK 



Paralysis of right leg: Hysterical? Organic? 
" Micro-organic? " 



Case 410. (Von Sarbo, January, 191 5.) 

A Lieutenant, aged 28, lost consciousness September 6, 
1 9 14, as the result of a shell explosion. When consciousness 
returned in the hospital, he could not remember what had 
happened. The last he remembered was that he had been 
pushing forward with his troop. There had been no psychic 
shock whatever. Examined September 15, he showed a 
right- sided hemiplegia with stiffness of the right lower ex- 
tremity so that it could not be even passively flexed. It was 
with difficulty he could walk and he dragged his right foot. 
Patellar reflex could not be elicited on the right. Oppenheim 
and Babinski were absent. There was a slight nystagmus on 
looking to the right. Pupils normal. Tongue deviated to 
the left. Speech was slow and the man had to think a little 
over some expressions. He could not feel touch so well 
on the right as on the left and this hypesthesia grew more 
marked distally. He was greatly bothered because certain 
words did not come to him readily, especially names. 

The absence of the Babinski and Oppenheim reflexes was 
against an organic hypothesis and the absence of hysterical 
stigmata and the non-characteristic sensory disorder, as well 
as the absence of any psychic shock in the history, spoke 
against hysteria. The hypoglossus paralysis spoke in favor 
of the organic nature of the disease. 

According to von Sarbo we must look for the background 
of so-called functional nervous disorders, hysteria and 
neurasthenia, in structural changes of the nervous system, 
the changes that Charcot called molecular. But the lesions, 
he believes, do not lead to a degeneration of neurons. Ac- 
cordingly we get only the external form of organic paralysis 
without concomitant symptoms, such as Oppenheim and 
Babinski reflexes. Von Sarbo terms his hypothesis that of 
" microorganic " changes. To prove the hysterical nature of 
a condition we must show first that the symptoms have taken 
their rise on a mental or moral basis. 



THE DIAGNOSIS OF SHELL-SHOCK 573 



Shell-shock and momentary burial: Muscular 
weakness, followed (third day) by complete paraly- 
sis (save neck and head). Diagnostic hypotheses. 



Case 411. (Leri, Froment and Mahar, July, 1915.) 

A big shell burst October 3, 19 14, a little over 3 meters 
from a soldier crouching in a shallow Saint Mihiel trench. 
The shell made a hole two meters in diameter and 1.5 meters 
deep, and covered the man with loose earth, from which he 
was readily released. During the next few days, the man 
found difficulty in following his comrades on short marches 
(1 to 4 kilometers) . He was unable to buckle on his knapsack. 
The patient was himself not alarmed at his condition. 

Up to the time of his accident, this man, a farmer, had never 
had any motor trouble, nor was there any nervous disorder 
in any of his relatives. He had been in several conflicts, 
August 24-25, September 4-6, in the Argonne and in the 
Haute Meuse, and he had never found it hard to keep up with 
his comrades. In fact, once in the Haute Meuse, he took part 
in an exceedingly difficult and hasty retreat, and only a week 
before the shell-shock above described he had put in a very 
long march. Thus a man, perfectly normal before the shock, 
had fallen into a general state of slight muscular paralysis. 

On the third day very suddenly this paralysis became com- 
plete. The wounded man, while sitting in the trench, found 
that he could not stand up either with or without the use of 
his hands. Now, that very morning he had marched three 
kilometers from his cantonment to the trench. He was sup- 
ported on the way to the relief post, hardly 200 meters away, 
and was then sent to the hospital at Bar-le-Duc. At this 
time he was so weak that he had to be fed like a child. 

For a period of three weeks he lay, unable to rise or sit up. 
There was one exception to the generalization of the paresis: 
the movements of the head and neck were normal. A general 
muscular atrophy set in during the three months, but gradu- 
ally diminished in amount. The diagnosis of myopathy was 
made, based upon the evident degree of lumbar wasting, 



574 THE DIAGNOSIS OF SHELL-SHOCK 

kyphosis, the man's attitude, gait, manner of rising, galvano- 
tonic contractions. 

The history was, of course, rather against the diagnosis of 
myopathy, as well as the marked atrophy of the hands and 
the existence of an incomplete R. D. Moreover the fact that 
he improved may be regarded as rendering the diagnosis of 
myopathy doubtful. 

Other diagnoses, less likely than that of myopathy, may 
be considered, — hematomyelia, recurrent traumatic polio- 
myelitis affecting the anterior horns, polyneuritis. 

Without making decision as to the nature of this case, L6ri 
proposes the question whether there is a shell-shock myo- 
pathy and whether there is a myopathy due to gas or to 
hemorrhage? 



THE DIAGNOSIS OF SHELL-SHOCK 575 



Shell-shock : Right hemiplegia with contracture and 
mutism. Cure by isolation and suggestion. Ques- 
tion of the relation between plantar arerlexia and (a) 
anesthesia (hysterical) or (b) contracture. 



Case 412. (Dejerine, February, 191 5.) 

A territorial infantryman, 36, of a nervous and impres- 
sionable temperament (father alcoholic), was blown up by a 
bomb October 3, 1914, between Bapaume and Arras. He 
was evacuated forthwith to the relief post. According to his 
own story, he spat blood, could not talk, and felt his right 
side weak. He was three weeks at a hospital in Paimpol, 
with the diagnosis of right hemiplegia with contracture and 
mutism. At Guingamp, an electrical treatment was fol- 
lowed by a gradual disappearance of the arm contracture. 

Examined by Dejerine, January 2, 191 5, he was found 
to be a tall, stalwart man with right leg contractured in 
extension, foot in equinovarus, heel raised. He walked, 
dragging the leg, which trembled ; the trembling then ex- 
tended to the rest of the body. In dorsal decubitus, the 
leg lay in adduction and internal rotation. He could lift 
the leg only 5 cm. above the bed, could only slightly flex leg 
on thigh, and could not at all flex thigh on hip. The leg 
could not be bent at all if he was requested to hold it stiff. 
Ankle joint movements were impossible from contracture. 
The equinovarus was in contracture which could not be 
corrected. Right hip movements were limited and painful. 
Muscular atrophy absent. 

Whereas on the left side plantar stimulation produced not 
only the normal flexor reflex but also the classical defense 
movements of flexion of leg on thigh and thigh on hip, — 
on the right side neither a needle nor a match, nor any other 
form of stimulation of the sole, produced any kind of reac- 
tion on the part of the toes, the fascia lata, or any leg muscles. 
Tested every day for some weeks, the result was always the 
same. The cremasteric reflex was weak on the affected side. 
Abolition of the plantar reflex and of the defense movements 



576 THE DIAGNOSIS OF SHELL-SHOCK 

on the right side was associated with an anesthesia and a 
hypesthesia of the right side of the body, involving complete 
anesthesia below the knee and hypesthesia of superficial 
and deep sensation above the knee. The buccal and lingual 
mucous membranes were also hypesthetic. The bony sensi- 
bility was lost in the foot and lower leg, and was diminished 
in all of the bones of the right side of the body. There was no 
contraction of the visual fields. The right corneal reflex was 
diminished. There were no other sensory defects. 

The man was also aphonic, being unable to utter a word or 
a sound except a jerky whistling sound like the letting off 
of steam. He was able to write out his history intelligently. 
He was very emotional, wept, and trembled all over when 
talking of wife and children. The spinal puncture fluid was in 
all respects normal. A laryngoscopic examination showed 
that the vocal cords were functioning normally. The long 
a could be pronounced distinctly, at the expense of great 
effort so that the larynx would finally be blocked. The 
laryngeal reflex was abolished. The laryngeal mucosa could 
be touched with a probe without producing the slightest pain 
or coughing reflex. By way of treatment, this case of hys- 
terotraumatism was given isolation and psychotherapy 
for two months without effect. But about the middle of 
March he began to get better, the symptoms rapidly faded, 
cure was effected at the end of March, and the man was 
evacuated to his dep6t. 

Re reflexes and contracture, see the views of Babinski re- 
produced under Case 385 of Paulian. 



THE DIAGNOSIS OF SHELL-SHOCK 577 



Shell-shock: Tic VERSUS spasm. 



Case 413. (Meige, July, 1916.) 

A soldier was bowled over in a trench by a big shell that 
burst nearby. He lost consciousness and was carried to the 
ambulance. But he came to, and was so absolutely well with 
a few hours' rest that he took part in a lively attack shortly 
thereafter and got a wound in the left arm, affecting slightly 
the ulnar nerve. He was sent to the Salpetriere for this ulnar 
nerve affection, when certain movements of his scalp were inci- 
dentally noted. 

The scalp movements were quick, affecting the fronto- 
occipitalis muscles as well as the auricular muscles. The dis- 
placement was from behind forward, and then from before 
backward, with slight oscillations of the ear; and at the same 
time, the forehead wrinkled or became smooth. The move- 
ment was involuntary and more convulsive than the some- 
what similar movements that many persons can execute with 
scalp and ears. The phenomenon appeared after the shock 
for the first time. He had not noticed it himself but the 
physician at the ambulance had called his attention to it. 
The soldier was not disturbed by the matter, either at that 
time or later. 

The diagnostician would consider, on the one hand, tic, 
and on the other, spasm. According to Meige, the man was 
a victim of tic. No case of such limited spasm appears to 
have been observed previously. However, the sudden devel- 
opment of these movements without previous history of tic 
renders the diagnosis somewhat doubtful. There was also a 
complete anesthesia to pin-prick in the present case over the 
whole right side of the scalp, face, and neck, even passing 
below^to involve the chest, shoulder, back, and upper part 
of the right arm, with hypesthesia decreasing toward the 
nipple and the elbow. The soldier was quite ignorant of 
this sensory disorder and had never before been examined 
for sensations. The examination was made with due pre- 
cautions to avoid suggestion. The question of anastomosis 



578 THE DIAGNOSIS OF SHELL-SHOCK 

between the facial nerve and the auriculo-temporal branch 
of the trigeminus and the auricular branch of the cervical 
plexus, and of their relations to the anesthesia and tic of this 
case, is raised. 

Re pathological movements such as tremors, tics, and 
choreiform movements, Roussy and Lhermitte divide the 
tremors (see also under Case 337) into typical and atypical. 

The atypical ones are either limited, or more usually 
generalized when they are merely parts of the Shell-shock 
syndrome. Sometimes the tremors are paroxysmal, aggra- 
vated by noises. Now and then, a condition of tremophobia 
appears (see Case 225). As for the typical tremors, see 
classifications under Case 337. 

Re tics, the tonic or postural tic is, according to Roussy 
and Lhermitte, much less common than clonic or spasmodic 
movements, which are Shell-shock phenomena like tremors 
and usually yield to psychotherapy if treated early. These 
tics are usually observed in and about the head, involving 
the sternomastoid, trapezius, and platysma muscles to pro- 
duce clonic contractions of the neck. Other tics involve 
coarser head movements, nodding, eyelid and facial spasms, 
bilateral or unilateral, and shoulder movements. Babinski 
has suggested that some of the tremors are possibly due to 
organic disease, in view of the fact that they are not readily 
influenced by psychotherapy. Meige has suggested that 
some of the tics may also be in some sense organic. As for 
the differential diagnosis of tremor and tic, according to 
Roussy and Lhermitte, the Shell-shock onset may be an indi- 
cator. The non-rhythmic and irregular nature of the tic 
movements, and their exaggeration on voluntary movement, 
may be of some importance. Most of the tremors appear 
to be attended by a certain degree of permanent contraction 
of the muscle groups concerned. Tremors cease when these 
contractions disappear. 

A point in treatment is that complete muscular relaxation 
should be obtained by having the patient open his mouth and 
breathe deeply. 

Re diagnosis of neurasthenia in this case, it may be 
inquired whether the term is properly used, and whether 



THE DIAGNOSIS OF SHELL-SHOCK 579 

there is not some confusion here betwixt neurasthenia and 
hysteria. 

Re hyperalgesia, Myers states that about 25 per cent of 
his Shell-shock cases have shown a variety of disorders of 
the skin sense. Hyperesthesia and over-reaction is one phe- 
nomenon in the list, but is far less common than hyperes- 
thesia. According to Myers, the hyperesthesia was more 
relative than absolute, and was probably due to increased 
affective response. 



580 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-shock; unconsciousness: Tremors, anes- 
thesias. Recovery by suggestion. 



Case 414. (Mott, January, 1916.) 

August, 19 1 5, between Ypres and Flamentieres, a Jack 
Johnson exploded one day about three o'clock in the morn- 
ing near an experienced gunner, who had been on service in the 
R. F. A. for 15 years, and in France during the present war 
10 months. He came to in the military hospital at Chatham, 
two weeks later, and was told he was lucky to be there at all 
as the shell had killed many comrades. He was transferred 
to Colchester, and thence to the Fourth London General 
Hospital. 

Sitting in a chair, the man showed continuous rhythmic 
movements of legs, hands, and jaw, exaggerated when he was 
spoken to. The tremor was almost a clonic spasm. Every 
now and then, the patient would start and look sidewise and 
upwards, as if a shell were about to drop. Hyperacusis was 
such that the firing of the guns as far off as Woolwich alarmed 
him. In telling his story, he would repeat the same words 
over and over. He dreamt of shells bursting. His sleep was 
disturbed with groaning and moaning. The face was flushed, 
and the palms sweating. Because of the constant tremor, he 
could not stand or walk without assistance, and it was diffi- 
cult to test reflexes. The tremor somewhat resembled the 
intention tremor of multiple sclerosis. He was unable to 
feel the prick of the needle on legs, left arm, or hand. He 
could not feel vibrations of the tuning-fork on feet, legs, or 
hands, though he could on the forehead. The fork was 
heard quite well six inches from the ears. There was some 
difficulty in recognizing colors. Bitter fluids could be tasted, 
but vinegar, salt, and various fluids, could not be recognized. 
He could not recognize tincture of assafetida, attar of roses, 
or oil of cloves, though nitrite of amyl, ammonia and glacial 
acetic acid were recognized. 

Major Mott felt that, though this prolonged severe disease 
in a long-service man might possibly be related to some or- 



THE DIAGNOSIS OF SHELL-SHOCK 



581 



ganic change in the brain, he might well treat him by sugges- 
tion. Major Mott told him that the careful examination 
just made showed that there was no organic disease, and made 
it certain that he would recover. In a fortnight, he sat in a 
chair without tremors and with a profound belief in Major 
Mott. 



582 THE DIAGNOSIS OF SHELL-SHOCK 



Hysteria as appendix to traumata. 



Case 415. (MacCurdy, July, 1917.) 

A private, 25, something of a liar and of rather a low per- 
sonality, had enlisted in the regular army in 191 1, but de- 
serted to become a football player. He reenlisted, and went 
to France in September, 1914, enjoying the first six months. 
He broke his ankles by falling into a deep dug-out, and got 
frost-bite. After three or four months in England, he found 
that he did not wish to go back to France. He was two 
months in barracks, and then went up the line in a good deal 
of a panic. Soon after, he was wounded in the thigh and was 
able to remain in hospital a fortnight, exposed, however, to 
shell-fire and given to starting at noise and occasional war 
dreams. Sent to his base, he remained jumpy and ^ras now 
permanently afraid of the line. After three weeks in the 
trenches, he again got wounds, spent five months in England, 
came back to France in May, and fought till September, 191 6. 
He tried to convince the medical officer that he had appen- 
dicitis and trench fever. 

About the middle of September he saw with horror a man 
crushed by a tank, and thereafter was markedly affected by 
the sight of blood. Another slight wound sent him to a rest 
camp for two weeks, whence he was again thrown into the 
line, suffering acutely from fear and horror of blood. In 
three days he fractured his left collarbone and wrist. He gave 
a pint and a half of blood for transfusion purposes, and in 
turn was shipped to England. On removal of the splint, he 
found " probably not without satisfaction " that the arm 
was paralyzed. It remained paralyzed for five months, until 
treatment in a special hospital eventually cured the arm; 
but upon cure of the arm, nightmares developed, — an in- 
dication, according to MacCurdy, of the strong resistance he 
felt to the idea of returning to the front. 



THE DIAGNOSIS OF SHELL-SHOCK 583 



Neurasthenic hyperalgesia after peripheral nerve 
injury. 



Case 416. (Weygandt, January, 1915.) 

A German volunteer, a sportsman, was under heavy shell 
fire after the middle of October, 1914, and was wounded in 
the upper arm in November, with an injury to the median 
nerve that occasioned severe pain. These strictly localized 
pains increased upon any sort of physical or mental strain. 
If he walked down steps he kept thinking he might have an 
accident, and then the pains set in with greater force. He 
became apathetic so that he did not eat, drink or urinate. 
If his head were touched he felt pain as if from an electric 
shock. He also felt the pain when he saw anybody approach- 
ing a door to close it, through apprehension of the noise. 
Meantime, the wound was well healed. The pulse was ac- 
celerated. The visual fields were only slightly contracted. 
The patient wanted to get well and go back to the service. 

Weygandt regards this hyperalgesia after peripheral nerve 
injuries as neurasthenic. 



584 THE DIAGNOSIS OF SHELL-SHOCK 



Military training: Peripheral neuritis in lead 
workers. 



Case 417. (Shufflebotham, April, 191 5.) 

Among fourteen cases of lead poisoning, members of the 
territorial forces, largely from North Staffordshire, was a 
patient suffering from peripheral neuritis. He had been in 
the dipping-house. Two years before going into the service 
he had been suspended for lead poisoning by the factory 
surgeon. Giving up his work at the pottery, he became a 
general laborer in a non-lead process factory. 

Three weeks after enlistment, the man began to complain 
of pains, tenderness in the arms, weakness of the wrists, 
headache, giddiness, nausea, and constipation. The bowels 
were opened by a large dose of epsom salts. On blood exam- 
ination the hemoglobin was found diminished 40 per cent; 
cells with basophilic granules were found to the number of 
500 per cu. mm. The face was characteristically pasty. 
There was albuminuria. Alcohol could be excluded. The 
man had to be discharged. 

All Shufflebotham's cases occurred from three to seven 
weeks after mobilization, nor have any cases ever been re- 
ported in territorials after their annual training. Con- 
stipation was invariable. In two cases returned to service, 
there was a recurrent attack. An epidemic could be ex- 
cluded. Shufflebotham suggests that the altered conditions 
of life, especially the marching and drilling, caused increased 
metabolism, setting free lead compounds from the muscles 
and organs of the body. It is true that a glost placer always 
works very hard with his muscles, but not with the muscles 
used by the soldier. 



THE DIAGNOSIS OF SHELL-SHOCK 



585 



Peripheral neuritis " cured by faradism. 



Case 418. (Cargill, February, 1916.) 

A Naval Service man, 20, was thought to have peripheral 
neuritis. A long history of pain and numbness in arms and 
legs, a well-marked analgesia and anesthesia over the anterior 
aspects of forearms and legs, and an anesthetic band across 
the front of the chest, seemed consistent with the diagnosis. 
The calf muscles tightly squeezed yielded no pain. Pins 
could be thrust without pain into the anesthetic areas. When 
told to say yes when the pin was felt, and no when it was not 
felt, the man persistently said no when the areas noted 
above were touched. The deep reflexes were normal. Fara- 
dism by wire brush at two sittings yielded a complete cure. 
It seems that once this man, after seeing his sister fall in a 
fit on returning from a funeral, retired to the garden and had 
a similar fit himself. 

Cargill found in 1052 sailors fifteen cases of total absence 
of one or both ankle- jerks; seven of the fifteen were probably 
cases of tabes. 

Re peripheral neuritis and hysteria (see under Case 387). 

Re differential diagnosis between peripheral neuritis and 
reflex (physiopathic) paralysis, Babinski and Froment offer 
the following table : 



Peripheral Neuritis. 

1. Motor disorder, degenerative amy- I. 

otrophy, and sensory disorder 
corresponding topographically to 
anatomical distribution of nerve 
(neuritic) topography. 

2. Amyotrophy very pronounced, re- 2. 

gardless of localization. 

3. Reaction of degeneration, especially 3. 

weakening or abolition of faradic 
excitability of muscles. 



Tendon reflexes, corresponding to 4. 
the muscular territory of the 
nerve, weakened or abolished. 



Reflex Paralysis and Contracture 

More or less segmentary topog- 
raphy. 



Amyotrophy variable; ordinarily 
well-marked but not so severe as 
that of neuritis. 

Reaction of degeneration absent, 
never marked weakening of fara- 
dic excitability, which is often 
normal and may even be exag- 
gerated. 

If reflexes are altered, they are as a 
rule exaggerated and never abol- 
ished. 



586 THE DIAGNOSIS OF SHELL-SHOCK 



Multiple wounds; signs of late tetanus 7-8 weeks 
later: Pain and contracture of neck, tetanic, 14 
weeks after trauma. Dysentery. Recovery. 



Case 419. (Bouquet, 1916.) 

A soldier invalided for endocarditis July 8, 1908, went 
back to the colors on his own request August 8, 1914. He was 
wounded at noon September 6, 19 14, in the attack at Abbaye 
Woods. He lay in the woods, with several comrades as 
badly wounded as himself, until September 10, eating berries 
and drinking rain water. He had five wounds in all; in 
left lower leg, thigh, left external malleolus, right calf, and 
left forearm. Moreover, he had dysentery. 

He was picked up by the Germans September 10 and 
carried by them to the ambulance at Saint Andre, where he 
was given belated first dressing. When the enemy retreated 
September 12 he was left behind and finally carried back 
September 13 into the French lines by a French physician 
who had been a prisoner likewise. A second dressing was 
given September 14 at Rambluzin. He was then carried in a 
sanitary train to Bar-sur-Aube, where, September 15, in- 
jection of antitetanic serum was given. He left Bar-sur- 
Aube on December 18, 1914, practically cured, though one 
of the wounds still needed care. The dysentery was still 
present and walking was difficult. He was then cared for 
at Auxiliary Hospital No. 102 in Paris. 

It seems that about six weeks after his entrance in the 
hospital at Bar-sur-Aube he had had some difficulty in 
opening his jaws, with acute pains at the temporomaxillary 
joint. Similar pains appeared a few days later in the neck, 
with a sensation of stiffening. The jaws still opened easily 
enough December 18, yet the man got pains in his jaws as soon 
as he began to speak. The pain and contracture in the neck 
region were sharp and permanent. Sometimes the con- 
tracture got more marked, and the board-like muscles could 
be felt stiffening under the examining finger. During such 
crises the patient had to lie or sit down. Sometimes the 



THE DIAGNOSIS OP SHELL-SHOCK 587 

pains descended below the shoulders along the vertebral 
column. The crises occurred more often in the night, in bed. 
The diagnosis of late tetanus was made, and alcohol rubs 
were given. The phenomena gradually disappeared. The 
dysentery also had not yielded to therapeutics until eight or 
ten days before the patient left the hospital. There was 
still, at the time of report, a certain difficulty in walking, with 
a tendency to use the external border of the left foot rather 
than the sole. 



588 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-shock: Spasmodic neurosis and neuras- 
thenia. Treatment without great success. 



Case 420. (Oppenheim, July, 1915.) 

August 19, 1 914, a shell exploded very close to a soldier, 
whose bread bag, cartridge container, and field flask were 
pulled away from him, but who was not himself wounded. 
He fell down. Shortly developed headache, vertigo, palpi- 
tation. In running he fell down repeatedly. Spasms soon 
appeared in the legs. He had previously suffered from gas- 
tric disturbances, and heavy food did not agree with him. 

At the time of admission to hospital he complained of great 
irritability, nervous twitching, formication in his limbs, war 
dreams, tachycardia. The heart boundaries were normal. 
The muscles of lower extremities were attacked by tonic 
spasms, and felt board-like. This tonic spasm occurred on 
each attempt at motion, very gradually disappearing when at 
rest. Passive movements also had the same effect. Fibril- 
lary tremor affected the left quadriceps. On each attempt at 
motion, pains were felt in the legs. At first the cramps were 
so severe that all locomotion or even standing was impossible. 

Treatment: Cold-water pack (Priessnitz), hyoscin in- 
jections, magnesium sulphate injections (5 to 10 c.c. of 
ten per cent solution), perineural injections, umbar spinal 
analgesia, — all without success. Fibrillary tremors per- 
sisted in the quadriceps and in the extensors of the toes. The 
tonic spasms on increased attempts at motion became com- 
bined with clonic twitchings. From the end of November 
on the patient made attempts to walk with straddling legs, 
and under considerable vibratory tremor. Picture of severe 
crampus-neurosis, combined with neurasthenia gravis. 



THE DIAGNOSIS OF SHELL-SHOCK 589 



SHELL CONCUSSION 

Cause physical from explosives — amnesia for shell episode 
and for a subsequent period — followed by traumatic 
neurosis 



SHELL HYSTERIA 

Shell heard — victims already unstable — rum issue prepar- 
atory? — OVEREMOTIONALISM — SENSORY AND MOTOR DISORDER 



SHELL NEURASTHENIA 

Headache, dizziness, insomnia, anorexia, visceral pain — 
victims, older men 



After H. P. Wright 



Chart 13 






590 THE DIAGNOSIS OF SHELL-SHOCK 






(a) Bullet- wound of forearm: Combination of hys- 
terical (brachial) monoplegia, and reflex (physio- 
pathic) disorders, (b) Refrigeration: Combination 
of hysterical paraplegia and reflex (physiopathic) 
disorders. 



Case 421. (Babinski, 191 6.) 

The forearm of a soldier was pierced in its lower part by a 
bullet, which produced no lesion of large nerve trunks or 
blood vessels. A complete brachial monoplegia followed. 
Every movement of the different segments of the arm was 
abolished. The hand and forearm were slightly atrophied, 
and were of a reddish salmon color. The temperature of the 
affected hand and forearm was about three or four degrees 
lower than that on the other side. The sphygmometric os- 
cillations of the forearm were twice as small in the paralyzed 
limb as in the healthy limb, but the systolic blood pressure 
was normal. There was a mechanical over-excitability of 
the muscles, and a slight exaggerat on of the bone and ten- 
don reflexes. The paralysis was in part of reflex (physio- 
pathic) nature. On account however, of the completeness of 
the monoplegia, and the fact that the reflex paralyses as a 
rule affect only the distal portion of the limb, the diagnosis 
of hysteria had to be made in addition to the diagnosis of 
reflex disorder. 

As a result of freezing, this patient had also a complete 
crural paraplegia. He showed vasomotor disorders and hy- 
pothermia of both feet, together with mechanical over- 
excitability of the muscles; and these latter disorders ap- 
peared to be of a reflex nature. The paraplegia, however, 
was of a hysterical nature. 

Re refrigeration, see Case 309 (Binswanger) of glossolabial 
spasm. 



THE DIAGNOSIS OF SHELL-SHOCK 



591 



Differential diagnosis of organic (central) monoplegia and 
reflex (physiopathic) contracture and paralysis. (Babinski- 
Froment.) 



Organic Monoplegia 

Paralysis often affects the whole 
extremity, either arm or leg. 



2. After several weeks of flaccid paraly- 
sis, as a rule contracture occurs. 



3. The upper extremity shows flexion 3. 

with clawhand. The lower ex- 
tremity shows contracture of 
extensors. The patient walks 
throwing his leg sidewise (De- 
marche helicopode). 

4. Tendon reflexes, a few weeks after 4. 

paralysis begins, exaggerated. 

5. Babinski sign in crural monoplegia. 5. 



Reflex Contracture and Paralysis 

Paralysis almost always partial. 
In arm paralysis, affects as a rule, 
fingers and hand. The leg is 
often affected at its origin, and 
then only partially. 

Paralysis may remain flaccid for a 
long time, and frequently co- 
exists with contracture, hyper- 
tonicity and hypotonicity of 
different muscular groups. 

The upper extremity in hypertonic 
cases often shows the main d'ac- 
coucheur, the main en benitier 
(holy- water- vessel hand), the 
doigts en tuile (crowded fingers). 
The lower extremity does not 
exhibit the sidewise movements. 

Reflex status variable. Hyper- 
reflexia often absent even in 
hypertonic forms. 

Babinski sign absent. The skin re- 
flex may be abolished but may be 
reproduced on warming the foot. 



592 THE DIAGNOSIS OF SHELL-SHOCK 



Slight bullet wound of hand : Flaccid paralysis with 
vasomotor and thermic disorder. A case "non- 
organic " in the ordinary sense and non-hysterical, 
i. e., reflex or physiopathic. 



Case 422. (Babinski and Froment, 1917.) 

Struck by his observations upon the persistence of tendon 
reflexes in narcosis in a wounded soldier, Babinski continued 
observations in the same general direction in a case which 
may be termed briefly one of hypotonia of the extensors of 
the hand following the passage of a bullet through the arm 
without nerve trunk lesion. 

This patient had flaccid paralysis of hand and fingers fol- 
lowing wound in second dorsal interosseous space and vaso- 
motor disorder and local hypothermia in the hand. There was 
a slight diffuse atrophy of the muscles of the hand, forearm, 
and arm; but this atrophy was not systematized, and there 
was no R. D. The tendon reflexes of the extremity were 
preserved. There were no signs of organic disease of the 
central or peripheral nervous system ; that is, in the ordinary 
sense of these terms. 

Was it a question of hysteria or of simulation? 

Babinski was struck by the following symptoms: 

First, the remarkably intense hypotonia, especially note- 
worthy in the thumb, a hypotonia quite equal if not supe- 
rior to that observed in paralysis following marked nerve 
lesions ; 

Second, mechanical over-excitability of high degree in the 
muscles of the hand and forearm, with retardation of the 
muscular response; and 

Third, electric over-excitability of the muscles, with what 
Babinski calls " anticipated fusion " of the faradic reactions. 

It appears that this patient had been wounded in Sep- 
tember, 1 91 4, and that the paralysis had developed hve 
months later. Before the development of this paralysis, 
there had been simply a meiopragic state. 

Without perforating the hand, the bullet had remained 



THE DIAGNOSIS OF SHELL-SHOCK 593 

in the wound, being excised therefrom three months afters 
the trauma. 

In January, 1916, — that is, some sixteen months after 
the injury and eleven months after the recovery of the paral- 
ysis, — the vasomotor disorder and the hypothermia, and 
the faradic, voltaic and mechanical over-excitability of the 
hand and forearm muscles, were in evidence. Hypotonia 
was marked, permitting an overfiexion of the hand upon the 
forearm. If the patient moved his forearm, the affected 
hand would hang and oscillate inertly; likewise in walking, 
seeming to obey only the laws of physics. 

In May, 191 6, the patient was invalided and found to be 
still in possession of the above-mentioned signs. Similar 
phenomena have been found in the mainfigee acrocontracture, 
and main d 'accoucheur ', and belong, in the opinion of Babin- 
ski, to a group which is neither hysterical nor organic in the 
ordinary sense of the terms. Vasomotor and thermic phe- 
nomena are in the foreground of the picture, and are, in fact, 
practically constant, though they vary somewhat in degree. 
They react abnormally to the temperature of the surround- 
ing medium; there is undoubtedly a local perturbation of 
the vasomotor and heat-regulating mechanism. There is 
also certain evidence of vascular spasm. The vasomotor and 
thermic disorders run parallel with the mechanical over- 
excitability of the muscles and the slowness of the response. 



594 THE DIAGNOSIS OF SHELL-SHOCK 



Chloroform to demonstrate asymmetry of reflexes. 



Case 423. (Babinski and Froment, 191 7.) 
A soldier, 26, sustained, September 22, 19 14, a bullet in- 
jury of the right calf. There was no fracture, as X-ray 
showed, but healing was slow, taking no less than three 
months. The right knee-jerk was a little stronger and a 
little sharper than the left, but the difference was contro- 
versial; and the difference between the two Achilles re- 
flexes was still more doubtful. 

Chloroformed October 10, 191 5: As the patient was going 
to sleep, even before the phase of excitation and motor agi- 
tation had passed, the two knee-jerks and left Achilles jerk 
had disappeared. They grew rapidly less marked before 
disappearing, and none of the tendon reflexes presented any 
phase of exaggeration while the patient was going under. 
At this point anesthesia was arrested. The right Achilles 
reflex, which had not disappeared, was sharply defined. It 
was even stronger than in the normal state and polykinetic. 
During the whole phase of awaking from the chloroform, the 
right Achilles reflex remained strong and polykinetic, without, 
however, any ankle clonus. Thus, the difference between 
the two Achilles reflexes became indisputable ; also the right 
knee-jerk reappeared before the left, and became stronger 
without any patellar clonus. At this time, the difference 
between the two knee-jerks was sharp and beyond cavil. 
This status, in which the knee-jerk and Achilles reflexes were 
asymmetrical, lasted about ten minutes after anesthesia 
ceased and lasted a little longer for the knee-jerks than for 
the Achilles jerks. 



THE DIAGNOSIS OF SHELL-SHOCK 595 



Reflexes under chloroform. 



Case 424. (Babinski and Froment, October, 191 5.) 
A soldier sustained a clean-cut wound of the supero-ex- 
ternal aspect of the right thigh without much destruction 
of tissue or any adherent scar. He showed marked lameness, 
September 15, 191 5, walking with his right leg extended and 
the foot in external rotation. There was a slight limitation 
of the movements of the hip joint in respect to internal ro- 
tation and flexion of thigh. The right knee-jerk was a little 
stronger than the left, and this condition persisted several 
days. After a few tests, the knee-jerk became even slightly 
poly kinetic. The Achilles jerks were normal and equal. 
There was no epileptoid trepidation of the foot, and no pa- 
tella clonus. There was a slight hypothermia of right leg, 
with ill-defined muscular atrophy. Walking caused pain. 

Chloroform anesthesia, September 20, 191 5, yielded an 
exaggeration of the knee-jerks with a suggestion of patella 
clonus even before the phase in anesthesia of motor excitation 
had set in. As anesthesia proceeded the exaggeration was 
rapidly lost on the left side but progressively increased on 
the right. In the phase of complete muscular resolution, 
when all the other tendon reflexes (such as the knee-jerk, 
Achilles jerk on the left side, the radial and olecranon re- 
flexes on the left side) were abolished, the patella clonus on 
the right side was perfectly distinct and could be elicited 
either by the usual method or by raising the thigh and letting 
it fall. On percussion of the patella tendon, a strong poly- 
kinetic reflex was obtained; right Achilles jerk preserved; 
right leg in external rotation. Internal rotation could be 
passively performed better than in the waking state, but 
this movement was still limited. As the man was waking 
from anesthesia, when reflexes were reappearing, there was 
a suggestion of left patella clonus — right clonus as strong as 
before. At no time any trepidation of the foot. The patella 
clonus on the right side lasted an hour after waking, at which 
time all the reflexes returned to their previous state. 



595 THE DIAGNOSIS OF SHELL-SHOCK 



Reflexes under chloroform. 



Case 425. (Babinski and Froment, October, 1915.) 
A soldier sustained a bullet wound, September 22, 19 14, 
in the right calf. There was no fracture, as X-ray showed. 
Cicatrization was slow and took at least three months. He 
was examined October 2, 191 5, at the Pitie, — not complain- 
ing of pains, but lame. There were no pains, limitation of 
movement, or joint sounds in the hip joint, and X-ray was 
negative. There was a slight atrophy of the limb, 1.5 cm. 
less in circumference on the right. There was a sharply de- 
fined local hypothermia of the right leg up to the knee. The 
right knee-jerk was a little stronger and brisker than the 
left, yet it was difficult to be sure of this, and there was a 
still more doubtful difference between the Achilles reflexes. 

The man was anesthetized with chloroform, October 10. 
As he was going to sleep, before the phase of excitement and 
agitation had ceased, the two knee-jerks had disappeared. 
At the same time, the left Achilles jerk vanished, followed by 
the plantar cutaneous reflexes. Anesthesia was then stopped. 
The right Achilles jerk, which had not disappeared at any 
time, remained distinct. It was stronger than in the waking 
state, and polykinetic. During the waking phase, this reflex 
remained strong and polykinetic, but there was no epilep- 
toid trepidation of the foot. Accordingly, under chloroform, 
the difference of the two Achilles reflexes had become very 
sharp. The right knee-jerk reappeared before the left and 
became stronger, though without patella clonus. This dif- 
ference was much more striking than in the waking state. 
This asymmetry of the patella and Achilles reflexes lasted 
about 10 minutes after anesthesia was stopped, and lasted 
a little longer for the patella reflexes than for the Achilles 
reflexes. 



THE DIAGNOSIS OF SHELL-SHOCK 597 



Shrapnel wound above clavicle : Brachial mono- 
plegia, partly hysterical, partly organic. 



Case 426. (Babinski and Froment, 191 6.) 
Babinski speaks of certain symptomatic incompatibilities 
which emerged in the study of cases of combinations of 
hysteria, organic nervous disease, and the so-called physio- 
pathic disorders. An example of such an incompatibility 
might be that of a patient who should, three months after a 
sudden hemiplegia, show complete or almost complete flaccid 
paralysis and but slight exaggeration of tendon reflexes — 
yet the Babinski reflex. Of course, the Babinski reflex would 
permit a diagnosis of pyramidal tract disease. Yet a sudden 
intense hemiplegia lasting three months, if it were merely 
a matter of pyramidal tract disorder, ought to show hyper- 
reflexia of a pronounced degree as well as contracture. An 
example from the arm is as follows: 

A soldier got a shrapnel wound in the left supraclavicular 
region, and had a complete paralysis of the arm, which had 
lasted more than a month. Electrical examination showed 
marked reaction of degeneration in the muscles controlled 
by the musculo-cutaneous nerve, as well as a diminution of 
electrical excitability in the muscles innervated by radial 
branches. On the contrary, in the circumflex territory, ulnar 
and median, electrical excitability was normal. There were 
no vasomotor disorders. The diagnosis of an association of 
hysteria and organic disease was made. Babinski affirmed 
that electrification would effect a partial cure ; and in point of 
fact, the patient, after having submitted to the current for 
several minutes, was able to use all the muscles whose faradic 
contractility was normal or almost normal. Thus, he could 
raise his arm, flex the thumb, flex the fingers, close the hand, 
and extend the hand and fingers. Flexion of the forearm on 
the arm was still difficult, since there was, in fact, a reaction 
of degeneration in the muscles of the anterior region of the 
arm. The fact that the movements could be partially exe- 
cuted was dependent upon action of the supinator longus. 



598 THE DIAGNOSIS OF SHELL-SHOCK 



Gunshot fracture of upper arm; recovery with 
motor power in five weeks : Six weeks later, ErVs 
palsy (plus). Hypothesis : " Reflex paralysis " pre- 
ferred. 



Case 427. (Oppenheim, January, 1915.) 

A reservist, 26, was shot through the middle of the left 
upper arm, sustaining an oblique fracture of the humerus, 
August 26. The external wounds healed in a month; the 
fracture somewhat later. The left arm was at first stiff and 
motionless, but in five weeks it could again be moved. Pains 
disappeared with return of motility. 

About the middle of November the arm began to lose power 
to move again, especially the muscles of the upper arm. 
November 20, the patient showed atrophic paralysis (left 
deltoid, biceps, brachialis internus, and supinator longus) 
suggesting at first glance the appearance of an Erb's palsy; 
but the triceps and the adductor of the upper arm were also 
unable to move and there was a slight paresis in the distal 
muscles of the extremity. There were no pains or other ob- 
jective disorders. 

The diagnosis of subacute poliomyelitis was considered. 
Electric excitability, however, was found to be normal, both 
faradically and galvanically. 

When patient walked, the left arm swung helpless without 
sign of innervation or any tonus. Abduction of the shoulder 
could also not be performed, though a slight flexion of the 
forearm shortly began to be demonstrable. If the patient 
inclined his head to the right, extended his hand at the wrist, 
and flexed the fingers forcibly, he could then flex the forearm 
somewhat, and a slight tension of the biceps and supinator 
longus developed. Sometimes fibrillary tremors developed 
in deltoid and biceps. 

Of course a transient peripheral palsy can be produced by 
pressure of the radial nerve without any change of electrical 
excitability, but such a change is not associated with atrophy. 

Neuritis and poliomyelitis producing an Erb's palsy without 



THE DIAGNOSIS OF SHELL-SHOCK 599 

any effect upon the electrical reactions is an hypothesis not 
to be entertained. 

Accordingly, the hypothesis of psychogenic or hysterical 
palsy may be set up. Yet an atonic atrophic palsy with loss 
of tendon reflexes (supinator) is inappropriate. According 
to Oppenheim, this case falls into the category of the arthro- 
genic atrophies. A simple muscular atrophy may follow 
disease of joints and bones. However, such cases have rarely 
shown a complete palsy, as in Oppenheim's case. 

In short, we return to the old doctrine of reflex paralysis, 
conceiving that a stimulus passing from the periphery influ- 
ences the gray matter in its trophic functions. 

How much effect had the psyche upon this condition? The 
patient had stuttered from childhood and had sustained a 
fracture of the skull at 9, following which his school work, 
especially mental arithmetic, had been poor. The lack of 
psychic inhibitions may play some part in the situation, but 
on the whole, the reflex hypothesis is preferred by Oppen- 
heim, the nerve conceived to be dynamically affected, the 
muscles organically. 



600 THE DIAGNOSIS OF SHELL-SHOCK 



Paralysis : Hysterical? organic? 



Case 428. (Gougerot and Charpentier, May, 191 6.) 

A soldier, 20, was wounded May 15, 1915, by a large num- 
ber of shell fragments, 15 of which struck the right leg, two 
producing serious injuries, — the one, a penetrating wound of 
the popliteal space followed by stiffness of the knee, later cured 
by extraction of the fragments; the other, causing a deep 
wound at the internal malleolus. The fragment was ex- 
tracted June 3, but osteomyelitis persisted and a fistulous 
contraction was developed in January, 191 6. There was a 
slight equinism. 

By contrast with these deep bony lesions of the right leg, 
on the left side a fragment had struck the dorsum of the left 
foot at about its middle point, along the extensors of the 
fourth and fifth toes. The fragment was removed toward the 
end of June, 1915. The wound closed in a fortnight, leaving a 
loose 20 mm. scar. The man complained of pains, which he 
called electrical, in the third and fourth toes, if one bore down 
on this scar, a symptom suggesting that the dorsal nerves had 
been injured. Immediately after the wound both legs had 
been paralyzed, according to the soldier. He had been able 
only to drag himself along on his shoulders. This indetermi- 
nate paralysis lasted three days. It may have been hystero- 
traumatic, or it may have been a sort of diffuse inhibition. 
Just after the injury, the left foot was in contracture, which 
gave place a month later to paralysis. Only the great toe 
was still able to move a little. In December, 191 5, the 
patient still could extend and flex the toes on the left side 
very badly, though he could execute movements easily on 
the right side. There was no stiffness of joints; there were 
no tendon reflex disorders. There were no trophic vasomotor 
or secretory disturbances. 

The diagnosis of hysterical paresis seemed warranted, but 
electrical examination showed that the troubles were organic. 
There was an increase in the faradic and galvanic excitability 
of the external popliteal nerve. The response was more 



THE DIAGNOSIS OF SHELL-SHOCK 601 

sudden than normal, and there was an increase in faradic and 
galvanic excitability in the tibialis anticus. There was a 
decrease of faradic and galvanic excitability in the extensor 
communis of the toes and in the external peroneus. 

Thus, this patient after being wounded in both feet May 
15, 191 5, paralyzed in both feet for a period of three days, 
undergoing a contracture of the left foot for a month, giving 
place to paralysis of foot and toes, with slow improvement 
from the end of July, 191 5, was still in this latter state in 
March, 191 6; though without trophic disorder, he showed 
faradic and galvanic over-excitability of the external pop- 
liteal nerve and of the tibialis anticus, pari passu with dim- 
inished electrical excitability for other muscles. 



602 THE DIAGNOSIS OF SHELL-SHOCK 



Paralysis : Hysterical? organic? 



Case 429. (Gougerot and Charpentier, May, 191 6.) 
A man was wounded Oct. 11, 1914, on the back of the 
right hand. Two hours later, he was attended at the relief 
post. At this time, his hand was straight, with ringers ex- 
tended. He said that he could not move his fingers, although 
there was no pain in them. Three hours after the wound, 
the hands swelled and the edema spread as far as the middle 
of the forearm. There was a long suppuration, complicated 
by lymphangitis. All of the fragments were removed October 
26, 19 14; healing was complete in three months. The 
swelling, however, persisted to June, 191 5, and when the 
swelling disappeared, the hand began to show drop-wrist. 
The wound was sutured between the second and third meta- 
carpals, and the X-ray showed that the bones had not been 
injured, nor had the nerves of the forearm muscles been 
touched. The situation was such that the case was cata- 
logued " functional paralysis." 

October 5, 19 15, the hand was still drooping, fingers ex- 
tended, and middle finger and ring finger trembling. A 
slight stiffness of wrist and fingers did not interfere with 
movements. Extension of the wrist could be made very 
slightly above horizontal. Flexion was not quite complete, 
nor were adduction or abduction. Extension of the fingers 
could be performed normally, as well as that of the thumb, 
but flexion was not quite complete. There was a slight 
palmar retraction. Such were the movements that could be 
produced electrically. Voluntarily, flexion of the wrist was 
good, abduction and adduction incomplete; extension could 
not be executed to the horizontal position. There was a 
tendency to flexion of the ring finger. When the patient tried 
to flex the middle and index fingers, these fingers trembled but 
did not flex. Weak extension and abduction of the thumb 
but without opposition could be voluntarily performed; 
adduction good ; flexion of the first phalanx, weak ; of second 
phalanx, better. Slight muscular atrophy of the forearm, 



THE DIAGNOSIS OF SHELL-SHOCK 603 

which was one centimeter less in circumference than the left. 
The hand was subject to a general atrophy; the skin reddish 
and moist. The X-ray showed a decalcification of all the 
bones of the hand and wrist ; trophic disturbance of the small 
carpal bones although the trauma had affected only the 
second interosseous space. No joint lesions or periosteal 
thicknesses were found by X-ray. There was a slight hypes- 
thesia of the palmar surface of the middle finger and of the 
index finger. The patient complained of sharp transient pains 
in hand and fingers. 

In this case, therefore, a wound of the back of the hand 
produced an immediate inhibition of muscular action in the 
forearm, a rapid edema of the hand and arm, lasting for 
eight months and followed by reflex disorders. 

There was a considerable diminution in faradic excitability 
of the flexor brevis of the thumb, the anterior cubital, the 
flexor brevis minimi digiti, and of the dorsal interossei, and 
slighter evidence of diminution of galvanic excitability in 
some of the muscles. 

Sollier is said to have been the first to remark trophic 
bone disorders in cases of neuropathic contracture. 

Re bone changes, Babinski enumerates trophic changes 
in the tissue of bones and joints amongst objective signs that 
permit us to distinguish the reflex or physiopathic disorders 
from the hysterical or pithiatic disorders. Objective signs 
of this group (indicators of reflex or physiopathic disorders) 
are: (a) Well-marked and persistent vasomotor and thermic 
disorder; (b) alterations of muscular tone (either hypo- 
tonus, hypertonus, or a combination of the two) ; (c) in- 
crease in the mechanical excitability of the muscles and 
sometimes nerves; (d) quantitative changes in the electrical 
excitability of the muscles, but without R. D.; (e) muscular 
atrophy and atrophy of skin, bones, and joints. For cases 
of this nature, see especially Cases 431 and 432 of Delherm. 



604 THE DIAGNOSIS OF SHELL-SHOCK 



Paralysis: Hysterical? organic? 



Case 430. (Gougerot and Charpentier, May, 191 6.) 
A man, 22, was wounded September 17, 1914, in the left 
hand, the bullet passing from the lower part of the fourth 
interosseous space out through the palmar face. The bones 
were not injured, and it was evident that only a few nerve 
filaments could have been injured; but he had a paralysis 
extending far beyond this region, which increased little by 
little from November, 1914, to August, 191 5. Babinski, ex- 
amining him in November, 191 4, had made the diagnosis of 
psychic paresis of the extensors with diminution of electric 
excitability, with a very slight slowing of the contraction of 
the last two interossei and the hypothenar eminence, con- 
nected with lesion of the branches of the ulnar nerve. The 
disorder spread to the flexors of the fingers and the thumb 
muscles. The fifth finger was flexed at rest; there was no 
stiffness of joint or tendon retraction. The extensors and 
flexors of all the fingers and the thumb, and the abductor of 
the thumb showed paresis. The thumb was able to oppose; 
the hands were cyanotic. Augmentation of these phe- 
nomena in a period of months, their bizarre distribution, and 
the preservation of the opposing power of the thumb sug- 
gested a hystero-organic disease, and Babinski' s notes read, 
" Partial and incomplete paralysis of the ulnar nerve, at- 
tacking slightly the hypothenar eminence and the last two 
interossei; psychic paresis of the extensors and flexors of 
the fingers and thumb and of the abductors of the thumb." 
Electrical examination showed, however, that there was not 
only electrical disorder of the common extensors of the 
fingers, the extensor proprius of the index and of the ring 
fingers, of the long and short extensors of the thumb, but also 
there was a considerable diminution to faradic and galvanic 
reaction in extensor ossis metacarpi pollicis, the radials, the 
supinator longus, the pronator teres, the large and small pal- 
mar, the common and superficial flexors of the fingers, the 
muscles of the thenar eminence, the anterior ulnar, and the 



THE DIAGNOSIS OF SHELL-SHOCK 605 

anterior biceps and brachial. In short, there was an irradia- 
tion of seemingly organic phenomena in the domain of the 
radial, median, and the non-injured part of the cubital 
distribution, as well as in the distribution of the musculo- 
cutaneous. Apparently, organic paralytic disorder had spread 
even to the biceps and had increased over a period of many 
months after the wound had healed. 

Re what he terms organo-hysterical association, Babinski 
proposes to distinguish it from hystero-organic association. 
In Babinski's organo-hysterical association, the organic symp- 
toms are preceded by hysterical symptoms. These cases 
of organo-hysterical association, — e.g., sl case in which a 
hysterical monoplegia is followed by a musculospiral crutch 
paralysis, — are one of the mainstays of the proof that 
hysteria and simulation cannot be confounded. Babinski 
concedes that he has sometimes said that hysteria was a 
sort of semi-simulation ; yet a semi-simulation is not a simu- 
lation. 

As for Babinski's hystero-organic association, we here deal 
with cases of organic paralysis or contracture in which the 
fundamental disorder is organic, and the psychic disorder is 
grafted upon it. Both the fundamentally organic and the 
fundamentally hysterical associations are instances, accord- 
ing to Babinski's phrase, of symptomatic incompatibilities. 
In such instances, the hysterical part of the disorder, whether 
grafted or original, is dissolved by psychotherapy. There is 
a third group of symptomatic incompatibilities, namely, 
the hystero-reflex associations, in which, e.g., a hysterical gait 
is combined with vasomotor and thermal disturbances. 
There may even be combinations of all three types of disease, 
namely, the type of structural disease, of vasomotor disorder, 
and of hysteria, in what would then be termed a hystero- 
reflex- organic association. 



606 THE DIAGNOSIS OF SHELL-SHOCK 



Wound of toes — Wound of arm : Reflex or physio- 
pathic paralyses, diagnosis and treatment. 



Cases 431 and 432. (Delherm, September, 1916.) 
A soldier was wounded in the soft parts of the last two 
toes and in the furrow between toes on the left side, Septem- 
ber 15, 1 914, arriving in the Central Physiotherapeutic Ser- 
vice of the 17th Army Region, December 27, 191 5, left foot in 
varus, with marked contracture of tibialis anticus, though 
passive movements of flexion, extension, adduction and ab- 
duction were well performed. There was a slight atrophy 
of the leg (33 cm. left to 34 cm. right). The scar was a 
little painful, and there was a slight degree of hypesthesia of 
foot and lower leg. The foot was cold and cyanotic ; the re- 
flexes were normal. An electric examination in the region 
of the external popliteal branch of the sciatic nerve showed 
that there was no electrical disorder either faradic or voltaic. 
Another case was wounded in the right arm by a shell 
fragment September 7, 19 14, and showed two scars above the 
epitrochlea and along the internal border of the triceps. 
Examination December 30 showed a normal elbow move- 
ment, pronation and supination, with slight flexion in repose 
of the palm of the hand and the fingers. Active flexion 
movements of the fingers could be performed only imper- 
fectly, and the ringer pad could only be brought within three 
fingers breadths of the palm, despite the greatest effort on the 
part of the patient. Minute passive movements were en- 
tirely possible. The fifth finger could not be abducted and 
both abduction and adduction of the third and fourth finger 
could not be made on account of the nerve lesion. The 
thumb was in a condition of contracture which placed it in 
abduction in front of the index finger, and the thumb could 
not oppose. Passive movements, on the other hand, were 
entirely possible. The hand was flexed upon the forearm 
through hypertonia of the flexors, which could be easily 
overcome with slight but distinct resistance. The hand was 
in the position of a radial paralysis. There was a slight de- 



THE DIAGNOSIS OF SHELL-SHOCK 607 

gree of muscular atrophy. Tendon reflexes were normal. 
Electric examination showed that stimulation of the ulnar 
nerve at the elbow was unable to produce flexion of the last 
two fingers or any movement in the hypothenar eminence, 
of which the muscles were also not excitable. The interos- 
sei could, however, be made to contract. The median and 
radial nerves were normal electrically. The above exam- 
inations were with the faradic current. 

With the galvanic current the ulnar nerve proved unex- 
citable at the elbow, and the muscles of the hypothenar 
eminence contracted more slowly. The median and radial 
nerves and their muscles were electrically normal. 

In short, there was a complete R. D. of the hypothenar 
and partial R. D. of the interossei as a result of the lesion 
of the ulnar nerve. There was nothing abnormal in the 
other nerves or muscles of the arm. The attitude of radial 
pseudoparalysis is due to the contracture of the muscles of 
the thenar eminence. 

As to therapy, the general movements of flexion of the 
fingers, thumb and hand yielded a marked improvement, 
but such results cannot be expected in like cases unless a 
physician or experienced masseur treats the case. Babin- 
ski and Froment have tried thermotherapy and diathermy 
in these cases, finding that the paralysis diminishes and be- 
comes partial if the limb is warm, although it is important 
that it should not become too warm. Sometimes a few 
treatments with diathermy will produce movements in a 
case of long standing paralysis. Babinski and Froment 
counsel not only diathermy, but a general motor reeducation. 
The idea of the diathermy is that the deeply penetrating 
heat affects blood vessels and muscles, bringing about a vaso- 
dilatation or even a direct addition of needed calories. In 
like manner, galvanism, light baths, or simple baths in com- 
bination, and with diathermy, especially with the diathermy, 
act favorably. Casts and apparatus have also proved with- 
out avail, as well as faradic or galvanic reeducation. 

The above two cases show how in one instance there may 
be no electrical change and in another instance a slight one. 
In these cases, reflex hypertonic contracture, hypotonic par- 



608 THE DIAGNOSIS OF SHELL-SHOCK 

alysis, vasomotor disorder, decalcification of the skeleton 
(X-ray), mechanical overexcitability of muscles, unmodified 
tendon reflexes (except elective exaggeration of reflex under 
anesthesia, e.g., a persistent unilateral patellar clonus when 
all other reflexes have been abolished), and disorders of elec- 
trical excitation are enumerated by Babinski and Froment. 
Delherm sums up the electrical disorders as follows: 
Muscle faradized: 

(a) No change. 

(b) Subexcitablity. 

(c) Overexcitability. 

(d) Diminished contractility to faradism, associated with 

increased contractility by galvanism (Char- 
pen tier) . 

(e) Anticipated fusion of shocks (Babinski and Froment). 
(/) Slow contraction and decontraction on faradism 

(Charpentier). 
(g) Rapid exhaustion of rhythmic faradic contraction 
with metronome. 
Muscle galvanized: 
{a) No change. 

(b) Subexcitability. 

(c) Overexcitability. 

(d) Suddenness of galvanic contraction with subexcit- 

ability. 
Re decalcification and osteo-articular changes, Babinski 
points out that the reflex or physiopathic phenomena run 
historically back to John Hunter, Charcot, and Vulpian. 
Charcot and Vulpian called especial attention to the peculiar 
amyotrophy and paralysis which occurred in joint disease, 
and upon the lack of parallelism betwixt the intensity of the 
joint disease and the severity of the paralysis or atrophy. 
The atrophy was without R. D. 



THE DIAGNOSIS OF SHELL-SHOCK 609 



Shell-shock : Functional blindness (monosymp- 
tomatic). 



Case 433. (Crouzon, January, 1915.) 

A shell burst above the head of a sergeant in a battle near 
Neuf chateau, August 22, 19 14. The man was kneeling at 
the time; felt a terrible shock, slipped prone, lost conscious- 
ness and woke in the evening blind. Next day he could 
hardly distinguish light from dark. Yet the light reflexes 
were normal ; the fundus was normal. 

This Crouzon calls the symptomatic triad for functional 
nerve blindness of Dieulafoy. There have been similar cases 
following eclipse of the sun and nervous shock. The eclipse 
cases suggest that the bright flash might have something to 
do with the sudden blindness (yet blindness has appeared in 
cases in which the shell burst behind the patient). 

The diagnosis of temporary blindness, with a prognosis of 
early recovery, was made. The neurological examination 
was normal. 

For its suggestive effect, glycerophosphate injections and 
progressive reeducative measures were adopted. The patient 
was shown that he could see, first, the contour of objects, 
then details and colors, then large letters and later small 
letters. In a month the blindness was almost well. Five 
months afterwards there was still a certain haze' over the 
field of vision and a slight difficulty in distinguishing certain 
colors. 

Jousset states that aside from visual alterations as the 
result of cranial trauma, and aside from various transitory 
amblyopias such as scintillating scotoma, the main varieties 
of amblyopia are : 

First, Congenital amblyopia. 

Second, Amblyopia due to cerebral intoxication. 

Third, Retrobulbar neuritis and toxic amblyopia. 

Fourth, Amblyopia ex anopsia. 

Fifth, Hysterical amblyopia. 

The most frequent amblyopias among the soldiers are ex- 






6lO THE DIAGNOSIS OF SHELL-SHOCK 

anopsia. Aside from a few amblyopias caused by prolonged 
occlusion of the eyelids, ptosis, or blepharospasm, the most 
frequent are due to opacities, ametropia, and strabismus. 
The hysterical amblyopias are, as a rule, associated with 
blepharospasm due to intense photophobia, and are some- 
times associated with constant lacrimation. Vision at a 
distance is poor. The patient succeeds in reading but shows 
an asthenopia of fatigue. The cornea and the conjunctiva 
are anesthetic, and sometimes the eyelids also, — the so- 
called anesthesia en lunettes. The pupils are large but react 
properly. The patient complains of many species of dis- 
order; loss of the sense of the third proportion, micropsia, 
megalopsia, diplopia, erythropsia, diplopia in two colors, in- 
verted image, hemierythropsia, rotatory amblyopia. There 
is concentrated limitation of visual fields, exaggerated by 
fatigue and by intense light ; reduced in dim light or when 
the patient is provided with smoked glasses; enlarged upon 
the instillation of atropin or with convex glasses. As a 
rule, with unilateral amblyopia, the functional disorders start 
in binocular vision. Practically the most important diag- 
nostic feature is the anesthesia, since this cannot be readily 
simulated. Sometimes corneal anesthesia is found in non- 
hysterical persons, who may perhaps be regarded as poten- 
tial hysterics. 



THE DIAGNOSIS OF SHELL-SHOCK 6ll 



Retrobulbar neuritis (nitrophenol). 



Case 434. (Sollier and Jousset, April, 191 7.) 

A soldier of the 54th Artillery entered hospital 45, Novem- 
ber 4, 1 916. He had had a slight paralysis of the left bra- 
chial plexus in 1913, following a shoulder dislocation, but the 
only relic of this when the war began was a deltoid paresis. 
He had been working from August 13, 191 5, at the factory 
in Saint- Fons, and was as yellow as the majority of the 
workers there. He had never shown xanthopsia. 

The first symptoms of his left brachial plexus neuritis had 
begun six months before, after 9 months' work in the factory, 
and showed themselves in an increase of the deltoid paresis, 
with pains in the hand and forearm, and cramps of the hand, 
interfering with work, formication in the right hand and in 
the feet, diminution of visual peculiarity (objects forgotten 
and reading difficult). It was only in November that he got 
perturbed about these difficulties, which had begun in May. 
There was a paralysis of the levators and rotators of the left 
shoulder, with a slight atrophy of the deltoid and of the 
supra- and infraspinatus muscles. The arm could be ex- 
tended almost to the horizontal with difficulty. There was 
one centimeter atrophy. The forearm and hand were not 
atrophic but slightly weak. There was an anesthesia of the 
shoulder- joint region, and of the outer surface of the arm; 
a hypesthesia of the posterior surface of the forearm and 
dorsal surface of the hand and fingers ; tendon and periosteal 
reflexes normal. Sometimes the hand would contract firmly 
and could be opened only by the aid of the other hand. The 
nerve trunks of the axilla, upper arm, and forearm, were 
painful on pressure, especially on the left side, and the ulnar 
nerve was thickened and rolled under the finger. The knee- 
jerk and Achilles jerk were abolished on the right; plantar 
reflex diminished ; right posterior tibial nerve painful on pres- 
sure, and its territory was hypesthetic. There were cramps 
in the feet. 

Gymnastics and electrotherapy and rest reduced these 
phenomena. The eye grounds were normal ; there was a 



612 THE DIAGNOSIS OF SHELL-SHOCK 

paresis of accommodation, and an absolute blindness to 
green, with retraction of fields to 15 degrees in the right eye, 
and 20 on the left. There later developed a slight edematous 
neuritis of the nerve, corresponding to the evolution of a 
chronic retrobulbar neuritis of toxic origin. 

It is the chronic retrobulbar neuritis which is typical of 
the so-called nitrophenol neuritis, developing in soldiers em- 
ployed in making explosives. The above case is accordingly 
exceptional in its association of a severe peripheral neuritis 
with the optic neuritis. Typically, after six months to a 
year in the factory, the cramps and formication of the legs 
are felt, and the gradual diminution of vision with transient 
blindness, finally leading to inability to read, sets in. The 
green blindness, the accommodative paresis, and diminution 
of central vision, the concentric contraction of the visual 
fields, are the usual story. At first the eye grounds are 
normal; there is then an edematous neuritis, and finally a 
white atrophy. According to Sollier, the accommodative 
paresis is like that in post-diphtheritic paralysis — a dis- 
ease due to cerebral cortex intoxication. In fact, the photo- 
motor reflex is normal, and what we have is an inversion of 
the Argyll- Robertson sign. These symptoms are those of 
retrobulbar neuritis, of nicotino-ethylic origin, and it may be 
thought that the melinite was simply acting by creating a 
soil for alcoholic intoxication, but none of the patients ex- 
amined has been alcoholic, nor has any been permitted to 
smoke in the factory. The injurious agent is probably a 
body in the nitrophenol series, perhaps dinitrochlorobenzol, 
but whether this substance is absorbed through the skin, 
inhaled, ingested from the hands, or by all three routes, is 
doubtful. These workers are often cyanotic while at work 
because the nitre products produce vasodilatation. Possibly 
this dilatation of vessels has something to do with the neuri- 
tis. The workmen will not use the spectacles and antitoxic 
masks given them, and even do not use the rubber gloves 
constantly. In some factories only, a liter of milk is given as 
counterpoison, every day. 



THE DIAGNOSIS OF SHELL-SHOCK 613 



Slight wound of occiput : Ophthalmoplegia externa, 
influencible, however, by tests and replaced by 
spasmodic convergence of globes with myosis ; hys- 
terical stigmata and convulsions. 



Case 435. (Westphal, September, 191 5.) 

A German volunteer, 20, was slightly wounded in the 
occiput by revolver-shot at Ypres. Then followed head- 
aches, vertigo, and complaints of pains in the eyes such that 
he could not open them or see side wise. May 5, 191 5, he 
showed a picture of an ophthalmoplegia externa: complete 
immobility of the two bulbi, lively blepharoclonus, rapidly 
passing into blepharospasm, photophobia. The visual field 
for white was practically limited to the fixation point. Cen- 
tral scotoma for all colors. Otherwise normal. 

On further examination, the apparently immobile bulbi 
were found to pass into convergence upon request to look to 
the right or left. Thereafter, this position of convergence 
was assumed if any test made by a strong light, such as that 
of a pocket flash, was used. The pupils contracted to the 
maximum during this assumption of the convergent position 
of the globes, and no further light reaction could be observed. 
The convergence gradually passed off when the light was 
removed. The appearance of bilateral external ophthal- 
moplegia had disappeared. 

If the patient was requested to follow a finger moved to 
one side, the globe of that side to which the finger was being 
moved, stood unmoved in its central position, but the other 
globe followed the eye and placed itself in the convergent 
position. The patient complained of diplopia. Even after 
the closure of one eye a double vision appeared (monocular 
diplopia). There was achromatopsia. The cornea failed to 
react to stimulation. 

There was an analgesia of the skin of the whole body, with 
a hypesthesia for tactile stimuli on the left side. Smell and 
taste absent. The convergent position of the globes with 
myosis was preserved in the midst of convulsive seizures, 



614 THE DIAGNOSIS OF SHELL-SHOCK 

which could be produced by exciting the patient. When it 
was attempted to dissolve the eye troubles by hypnosis, con- 
vulsive attacks occurred. The patient was pronouncedly 
hysterical. 

The case is beyond question hysterical, — the phenomena 
consisting of an ophthalmoplegia externa, alternating with 
spasmodic contracture of the internal recti, associated with 
myosis and loss of light reaction. The influencibility of this 
situation during the process of tests, to say nothing of the 
other stigmata, clinches the diagnosis — an important one, 
since the development of an external ophthalmoplegia after 
occipital trauma might possibly be regarded as an organic 
disease due to hemorrhage in the region of the eye-muscle 
nuclei. 



THE DIAGNOSIS OF SHELL-SHOCK 615 

_ — c 



Sandbag drops on head: Internal strabismus and 
diplopia. Various diagnoses. Cure by lenses. 



Case 436. (Harwood, September, 1916.) 

A four-pound wet sandbag fell eight feet on the head of a 
sergeant-major, 28, lying in a Gallipoli dug-out, November 
24, 1 91 5. The sergeant-major was removed to Lemnos with 
headache and giddiness, and a week later developed bilateral 
internal strabismus with double vision and head noises. 
The diagnosis was " brain tumor" or "syphilitic meningitis 
of the base." On the voyage home, the diagnosis was altered 
to " multiple neuritis or neurasthenia." 

He was admitted to the King George Hospital, January 1, 
191 6, unable to move the eyes outwards; they moved rather 
poorly up and down. There was a slight lateral nystagmus. 
The patient had been unable to read or stand since the acci- 
dent. The visual acuity of each eye was less than 6/60, but 
with an arrangement of lenses he could get 6/5 with either 
eye. He had perfect binocular vision and could read ordi- 
nary type comfortably. In a week's time he was able to 
stand without support and walk with a stick. Whenever he 
took off the glasses, the strabismus and diplopia immediately 
returned. Other combinations were tried but failed to re- 
lieve symptoms. The lenses given were +0.375 c. Vert, and 
L. +0.25 S. +0.25 C. 75 do. 



6l6 THE DIAGNOSIS OF SHELL-SHOCK 



Hemianopsia : organic or functional? 



Case 437. (Steiner, October, 191 5.) 

A 19-year old volunteer, never ill (no nervous disease in 
the family), after a period of training went into the field, 
October 3, 19 14. November 5, a shell struck the trench 
nearby but failed to explode. Up to that time everything 
had been quiet. The soldier had been looking out of the 
loophole, surveying the terrain. He felt a great fear, got a 
blow in the neck, fell down unconscious, remained uncon- 
scious for an unknown time, and later walked back with his 
comrades. About an hour later, this volunteer, — who was a 
very intelligent young man, possessing much knowledge of 
biology, including the nature of visual fields, — noticed a 
black spot in the field of vision, which came and went, but 
after a few hours remained continually without disappear- 
ing. Otherwise, there was no complaint except a feeling of 
dizziness when stooping. 

Upon examination there could be found no disorder of the 
internal organs. Neurologically there was blinking, vaso- 
motor excitability, slight reddening of the face, and dermato- 
graphia. An expert in ophthalmology confirmed the exist- 
ence of a homonymous defect in the fields of vision. This 
defect could not be influenced by suggestion or by any other 
treatment, nor did any other change whatever occur in the 
condition. 

Steiner inquires whether this hemianopsia is to be taken as 
organic or functional. The air-pressure of the shell hissing 
past might have produced a concussion, or the falling uncon- 
scious might have produced a commotio cerebri or a slight 
hemorrhage. The tic-like blinking and vasomotor excita- 
bility, however, suggest functionality. 



THE DIAGNOSIS OF SHELL-SHOCK 617 



Hysterical pseudoptosis. 



Case 438. (Laignel-Lavastine and Ballet, January, 
1916.) 

Laignel-Lavastine and Ballet present a case of what they 
term hysterical pseudoptosis in a patient who showed no 
signs of organic disease of the nervous system, and moreover 
no special mental disorder. This soldier, 30 years of age, 
working in the auxiliary service, suffered from a trouble- 
some lowering of his left upper eyelid. He went to the front 
in February, 1915. Aside from suffering a few mild and 
temporary blindnesses (eblouissements) , he was entirely well 
up to the time of being wounded, March 18, 1915, by a 
bullet in the arm, and a bullet occasioning a superficial and 
slight wound 2§ centimeters above the middle of the left 
eyebrow. About three years later, a shell burst near him 
and made a large contusion about the right eye, without 
hurting the globus. He was then evacuated to Chalons-sur- 
Marne, and there remained for 48 hours, totally blind, prob- 
ably on account of spasmodic closure of his eyelids. He 
then began to be able to use the left eye, which remained, 
however, very photophobic. A fortnight later, the wounds 
were healed, but the patient found himself unable to open 
his right eye. Three months later he returned to his depdt, 
and left for the front October 24. 

He was reevacuated November 4, as unsuitable for ser- 
vice. He was then examined by an ophthalmologist at 
Chartres, who found a very mobile right pupil and a slightly 
atrophic right papilla; vision J; left eye normal; vision f ; 
total paralysis of right levator palpebrae superioris without 
contracture of orbicularis. There was also paresis of the 
left upper lid, which ceased when the right eye was closed. 
The right half of the face was anesthetic, but there was no 
corneal anesthesia. 

November 15: Right eyebrow lower than left; if the head 
was moved backward, the right eyelid followed the move- 
ments, and in this position there was no ptosis. 



6l8 THE DIAGNOSIS OF SHELL-SHOCK 

November 16: Analgesia in the super- and sub-orbicular 
region. November 17: frontalis and orbicularis functions 
normal. 

At time of examination, patient complained of not being 
able to open his right eye, and that he could only partly open 
the left eye. To catch a view of his examiner, he had to 
throw his head back and to the right. He could not open 
his eyelids, and in the effort to do so, the forehead muscles 
contracted; and whereas the left eyebrow was properly 
elevated, the right eyebrow was only partially elevated. 
Associated movements could be noted in the musculature of 
the lower part of the face. In looking to the right, the eye- 
lids, especially the left, were elevated slightly. The patient 
complained of photophobia. From time to time, he felt 
completely blind, and at the end of these spells of blindness, 
he had a severe headache. His head felt heavy. Some- 
times on looking to the left, he saw objects double, although 
this diplopia had grown less marked of late. All the muscles 
of both eyes appeared to work normally. Upon pressure on 
the right globus, especially pressure directed from above and 
behind on the internal part, the patient would raise his left 
eyelid, but the paresis reappeared the moment the pressure 
was released; a fact which the patient himself noted while a 
tampon was being placed upon his eye. 

It seems there had been a wound at the external angle of 
the eye, some nine or ten years before, as a consequence of 
which the eyelid of this side could never be parted as well as 
before. The accident in question had happened in 1905, 
and there had been a slight suppuration of a wound 2§ centi- 
meters from the external angle of the palpable fissure. 

The patient then went through a period of reeducation. 
It seemed that when he was trying to raise his eyelids, there 
was a mental inhibition which could be overcome only by 
effort. An attempt may be made to resolve the phenomena 
into three groups : 

First, enophthalmia of the right side (post- traumatic, ante- 
bellum, a predisposing cause). 

Secondly, a situation corresponding to so-called hysterical 
pseudoptosis of Charcot and Parinaud (eyelid falling with- 



THE DIAGNOSIS OF SHELL-SHOCK 619 

out wrinkles, head thrown back, frontalis contraction on - 
effort to open eyes, eyelid lowered) . The diagnosis of hysteria 
was supported by the transient opening of both eyelids when 
a sudden sharp order was given to move the eye-balls, and 
further supported by synergic automatic lid- movements when 
the patient voluntarily raised his eyes. He could not raise 
his eyelids to order. 

Thirdly, functional ocular palpable synergy (left eye open- 
ing upon compressing the right eye). 



620 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-shock Rombergism. 



Case 439. (Beck, June, 1915.) 

A soldier, 24, had sundry signs of traumatic neurosis. A 
curious and unexplained feature is the fact that in the course 
of testing for Rombergism he would fall forward like a log if 
his head were held in the vertical position, but if it were 
turned to the right he fell to the right; if it were turned to 
the left, he fell backward. Tests showed that he had no 
disease of the vestibular apparatus and no sign either of 
cerebral or of cerebellar disease. 

The question is raised whether shell-shock can produce a 
differential Rombergism such as hitherto would have been 
explained on the basis of some organic vestibular disease. 

Re Rombergism, see especially Bourgeois and Sourdille's 
(edited by Dundas Grant) remarks on disturbances of balance 
which, if of labyrinthine origin, obey Romberg's law, namely, 
are greatly increased with the eyes closed. Upon test, how- 
ever, normal equilibrium, tottering, or a tendency to fall will 
be usually found. The tendency to fall is, as a rule, toward 
the side of the affected labyrinth, yet it varies according to 
the position of the head; that is to say, actually upon the 
position of the labyrinth with relation to the body. If there 
is a lesion of the right labyrinth, for example, and the head 
is turned to the right, falling is to the right; but if the head 
is turned 90 degrees toward the right, the patient tends to 
fall backward because in fact the injured right labyrinth has 
now become posterior in position. But if the head with the 
injured right labyrinth is displaced 90 degrees to the left, the 
tendency would be to fall forwards. 

According to Beck, there was in his case of Shell-shock 
Rombergism no ear disease or any evidence of cerebellar or 
cerebral disease. 

Walking with the eyes open yields in marked instances a 
sidewise bending or even the classical staggering called the 
duck's walk and drunken gait upon a broad base. The 
most delicate test, according to Bourgeois and Sourdille, is 









THE DIAGNOSIS OF SHELL-SHOCK 621 

the Babinski-Weil test of walking with the eyes shut. A 
man with labyrinthine disease deviates from the straight 
path (he is made to walk forwards and backwards ten times 
in a clear space) ; bends pretty constantly to one side when 
walking forward, and pretty constantly to the other side 
when walking backwards. Spontaneous and Babinski's in- 
duced nystagmus (rotation; caloric) and Babinski's voltaic 
vertigo test are the other tests commonly employed in 
equilibrium investigation. 



622 THE DIAGNOSIS OF SHELL-SHOCK 



Otology and neuropsychiatry should go hand in 
hand. 



Case 440. (Roussy and Boisseau, May, 191 7.) 

A soldier in the engineers, 29, entered the neuropsychiatric 
center at Scey-sur-Saone, August 23, 1916. His diagnosis 
was: organic shock syndrome with right-side deafness and 
tremors. He carried a ticket showing an otological exam- 
ination : tympanum normal ; Rombergism absent ; walks with 
eyes closed swerving to right ; tends to fall, eyes closed, on 
standing on one foot; vertigo produced by rotation in either 
direction ; no nystagmus either spontaneous or by test ; deaf- 
ness especially on the right side; equilibrium function in- 
sufficient. 

The patient had undergone shock in April, 191 5, being 
buried and then losing consciousness for twenty-four hours. 
The tremors appeared next day, and also deafness but with- 
out speech disorder. Nine comrades are said to have been 
killed beside him. The hospital ticket, April 13, said: deaf- 
ness and multiple contusions from shell explosion. The 
patient was evacuated to Clarmont-Ferrand and went back 
to service with the same tremor and auditory disorder. He 
was shortly sent back to the interior for six months and re- 
turned improved to the front August, 191 5. But he heard 
the cannon in the distance, and, under the influence of 
emotion and the fatigue of the journey, the tremors and 
deafness reappeared. 

The tremor was generalized, involving both arms and legs 
and a slight lateral movement of negation of the head every 
ten or twelve seconds. Occasionally tonic contracture of the 
face, lips, cheeks, forehead; tremors of tongue; winking. 
The tremors were somewhat suggestive of toxic tremors. 

The deafness was evidently exaggerated. Voltaic vertigo 
tested normal. Reflexes normal. 

The diagnosis psychoneurosis was made and the patient 
was rigorously isolated, given a long psychotherapeutic talk 
concerning the nonreality of his deafness and his vertigo and 



THE DIAGNOSIS OF SHELL-SHOCK 623 

the possibility of cure by means of a very disagreeable elec- 
trical treatment. He made improvement upon psycho- 
electrical treatment and the next day both tremors and deaf- 
ness had greatly diminished. September 4, the patient was 
considered completely well. There was a slight diminution 
of hearing in the right ear, the whispered voice was heard at 
50 centimeters on the right side, the watch at 25 centimeters 
on the right and 60 on the left. 

October 5 the patient was sent back to his corps. On the 
evening of his departure, angry at not having received leave, 
he boasted to his comrades of having passed but three days 
at the front since his injury. 

It is remarkable, according to Roussy and Boisseau that 
this patient had passed sixteen months without ever having 
been taken for a neuropath or treated as one. The otolo- 
gists gave the diagnosis of labyrinthine shock, but did not 
attend to the tremors. The pseudo-symptoms disappeared 
in six days at the neurological center and the cure had lasted 
six weeks at the time of report. 

Re otology in these cases, see Bourgeois and SoUrdille's 
book mentioned under Case No. 439, particularly Chapter 
III, upon the functional examination of hearing. In the 
present instance, it will be noted that voltaic vertigo tested 
out normal. According to Bourgeois and Sourdille, the 
Babinski electrical test is the most convenient one to begin 
with, to learn in a few moments whether the vestibular 
system is working normally or not. These authors found 
amongst twelve patients, three normal reactions and one 
instance of hypo-excitability amongst four subjects who, by 
other tests, failed to show vestibular disturbance. Inexcita- 
bility as to voltaic vertigo was found in one man with a 
destroyed labyrinth. There were four instances of hyperex- 
citability in Babinski's cases with marked equilibrium dis- 
order. A case of Meniere's disease yielded the same results. 
According to the intensity of the current, the following phe- 
nomena (in addition to the pricking sensation) are noted; 
(a) salty taste; (b) sidewise swaying with slight vertigo; 
(c) nystagmus with more pronounced vertigo; (d) sensa- 
tions of sound. In short, nerve branches that go through 



624 THE DIAGNOSIS OF SHELL-SHOCK 

the petrous bone, namely, the chorda tympani, the vesti- 
bular nerve, and the cochlear nerve, have been successively 
stimulated. Babinski's test was published before the Barany 
work on induced nystagmus, but Barany's rotation test for 
the physiological excitation of the semi-circular canals, and 
his caloric test for the investigation of the ears and canals 
separately are to be utilized in addition to the Babinski 
voltaic test. Babinski's law of voltaic vertigo is that a nor- 
mal subject inclines to the side of the positive pole; a patho- 
logic subject falls to the side to which he tends to incline 
spontaneously. If the labyrinth has been destroyed, there 
has been no reaction. 

Re Case 440, Roussy and Boisseau in their capacity as 
neuropsychiatrists, point out the inadequacy of an otological 
examination taken by itself. They insist that neuropsychi- 
atrists should be called in. It is probably equally true that 
neuropsychiatric work upon deaf cases is often inadequate 
on account of the lack of otological examinations. Accord- 
ing to Bourgeois and Sourdille, the expert otologist's prob- 
lems are as follows: (a) Deafmutism; here Gault's cochleo- 
palpebral reflex is of value. The hearing of a sudden noise 
causes contraction of the orbicularis palpebrarum on the 
side upon which the noise is suddenly and unexpectedly 
made. Eyelash tips are particularly watched. 

(b) Complete bilateral deafness. This is practically never 
organic; complete bilateral deafness is a phenomenon either 
of traumatic hysteria or of simulation. Sundry methods of 
surprising the patient into hearing have been adopted. The 
practice of teaching lip-reading to simulators and hysterics 
has led to some difficulties in diagnosis, but tests have been 
produced by Gosset (of one sound with the lips set to form 
another, and the like) which are of service. 

(c) Extreme bilateral dulness of hearing. 

id) Total unilateral deafness. For the minutiae of tests 
for these types of hearing disorder and their simulation and 
exaggeration, see the War Manual of Bourgeois and Sour- 
dille. 



THE DIAGNOSIS OF SHELL-SHOCK 625 



Jacksonian syndrome : Hysterical. 



Case 441. (Jeanselme and Huet, July, 1915.) 
A Lieutenant of Infantry, 32, was struck by a bullet Sep- 
tember 6, 1 914, in the upper part of the left temporal fossa 
4 cm. above the external auditory meatus. He did not lose 
consciousness, but had the sensation as if his head had been 
shot off, and about three minutes later he turned about, 
fell down, and lost consciousness. However, he regained 
consciousness a few minutes later and walked with support 
for about an hour. At the ambulance, he lost consciousness 
again, for half an hour. He was then carried to Amalie-les- 
Bains. The trip lasted 108 hours. The left side of the face 
was now swollen so that he could not open the eye nor 
could he chew from swollen mucosa folded between the jaws. 
The bullet was removed Sept. 12, from just below the scalp 
outside the bone, the point being slightly bent back. The 
bone had been depressed slightly for an area the size of a 
franc piece, and pressure at this point yielded a feeling of 
pain and discomfort. There was no suppuration. After a 
week, the man got up. He returned to his depot October 3 
or 4 and was about to rejoin his corps when he had a sensation 
of pressure in the head and fell. When he came to himself 
he found that there was a frothy saliva at the left side of the 
mouth and that the whole left side of the body felt weak. 
The tongue had not been bitten nor had urine been passed, 
and twenty minutes later he felt as well as ever. He re- 
turned to the front in the Argonne, having from time to 
time similar crises, — at least once a week. Ordered to take 
a trench the night of January 17, he failed the first time, 
about midnight, but succeeded at four in the morning, — just 
afterward falling exhausted in another crisis, with uncon- 
sciousness. The stretcher bearers took him back and he was 
evacuated to Perpignan. He had two convulsions. 

While with his family the crises grew in number to three 
or four a week, and sometimes twice a day. Upon request, 
he was sent to hospital in the Pantheon May 5. 



626 THE DIAGNOSIS OF SHELL-SHOCK 

There was always a sensory aura, consisting in a violent 
shock felt in the left side of the cranium like a blow of a club. 
There immediately followed a crawling sensation in the fin- 
gers and hand of the left side, running up the arm, with loss 
of consciousness coming on before the crawling reached the 
elbow. The seizure would last two or three minutes. There 
was no initial cry. The face grew pale. There was apnea, 
and frothy fluid running out of the left side of the mouth. 
There was no jerking of face or limbs; at the end of the 
seizure there were no deep inspirations. The extremities of 
the left side were rather flaccid during the attack. 

A hemianesthesia was found affecting both skin and 
mucosae of the left side, and a slight retraction of the visual 
field on the left side was found. There were no other sen- 
sory disorders; the knee-jerks were lively on both sides but 
not actually exaggerated. Plantar stimulation was not per- 
ceived on the left side. The toes, except the great toe, were 
slightly extended. The fascia lata reflex failed to demonstrate 
itself. On the right side the great toe went into flexion 
on forcibly stimulating the sole. Sometimes the abdominal 
reflex on the left side was weak or even absent. The 
patient, who had never been nervous, had now become so 
since his attacks. He had had nocturia up to 12. There 
was no evidence of neurosis or psychosis in the family. 
Bromides diminished the crises a little in number. Static 
electricity was given from January 8, — no attacks for 8 to 
10 days. 

According to Jeanselme and Huet, this is a case of Jack- 
sonian syndrome of an hysterical nature, about which it 
may be noted that the bullet struck the left side of the skull 
and the hemianesthesia and muscular resolution appeared on 
the same side as the injury. 



THE DIAGNOSIS OF SHELL-SHOCK 627 



Leg tic : Phobia against crabs. 



Case 442. (Duprat, October, 1917.) 

A man, shell-shocked in 191 6 (with loss of consciousness, 
disorientation and confusion followed by nightmares, mem- 
ory disorder, attention disorder, irritability, mental insta- 
bility and over-emotionalism) later still showed a choreiform 
tic. He had a knife-grinding movement of the left leg which 
made standing and walking difficult. There were no signs 
in the reflexes or reactions of organic disease. The man him- 
self said that he felt a sensation like little electric shocks when 
his foot touched the ground, a sensation like pinching. He 
also had certain hysteriform crises. He was able to remem- 
ber nightmares in which he felt as if he had fallen into a hole 
where there were crabs. In point of fact, he had a true 
phobia against crabs, crayfish, lobsters and the like; if he 
saw one, he always felt as if he were going to have a new 
crisis. The defense movement of the leg and foot was 
against a supposed pinch of the crab. At rest, there was no 
trace of the choreiform movement. The tic was especially 
marked when the man was suddenly asked to get up and 
walk. In a few days, when he had become more clearly 
conscious of his phobia and had slept better, the tic grew 
appreciably less. 



628 THE DIAGNOSIS OF SHELL-SHOCK 



Convulsions reminiscent of fright. 



Case 443. (Duprat, October, 191 7.) 

A soldier, 28, was blown up February 8, 191 5, by a shell 
burst. He sustained no contusions but became completely 
mute. On July 3, he began to speak in a low voice. The 
torpillage treatment was unsuccessful because the man felt 
a morbid apprehension that the vibration of a loud voice or 
even of a rapid walk would resound in his brain. He had a 
sort of noise phobia, probably maintained by nightmares 
which frequently woke him up with a jerk though he could 
not remember their content. On the way back to his depot 
this man got off the train at the first station and went to a 
hospital complaining that the vibration of the train was going 
to be transmitted to his brain. Hysteriform crises developed 
in a few days. 

According to Duprat these crises are nothing but a psycho- 
motor development of the initial complex. The clonic and 
tonic convulsions are reminders of his states of extreme 
fright, a phenomenon of revival of the ideo-affective process, 
aggravated however by the oniric or post-oniric images. 

Re diagnosis of hysterical fits, the absence of facial cya- 
nosis, sub-conjunctival hemorrhages, petechiae of skin, and 
the Babinski reflex are suggestive for hysteria. Babinski 
points out that the initial cry, the fall, the loss of conscious- 
ness, the tongue-biting, the bloody frothing at the mouth, 
the urinary incontinence, and the post-convulsive prostra- 
tion can all be consciously or unconsciously imitated. Hys- 
terical convulsive movements are apt to be of wide range, 
gesticulatory, and opisthotonic. 

Babinski announces to the supposed hysteric that he is 
going to reproduce the attack, as he is perfectly able to do 
by electricity. A mild current or mere electrode applica- 
tion suggests a fit in a hysteric, often very quickly. Babin- 
ski now announces that he can arrest the fit; carries out 
some selected procedure, and stops the fit. During the 
hysterical fit, the patient of course hears what is being said 
and during this time wrong suggestions must not be offered. 



THE DIAGNOSIS OF SHELL-SHOCK 629 



Fugue in a motor cyclist, with prodromal fatigue and 
subsequent delusions — recovery in six weeks. 



Case 444. (Mallet, July, 191 7.) 

A motor-cyclist, 36, with the colors from the outbreak of 
the war, about April, 1916, grew very weary, suffering from 
headache and seizures without loss of consciousness. Finally 
there was a voice: " Sleep, you must sleep." Then other 
voices; then ideas of thought transference with people 
around him. 

Observed in the psychiatric center, May 12, 1916, he had 
the same ideas of thought transference, and he made as if to 
talk with the attendants by responsive-looking gestures. 
Sometimes, he said, fluid struck his forehead, calling on his 
thought. Whereupon he listened. The man made no com- 
plaints about his plight, was not astonished in any wise at 
what was happening, nor did he seek to explain it. There 
was nothing in his history to suggest psychopathy except 
perhaps that his father was unknown. 

The diagnosis of a chronic hallucinatory psychosis was 
made, but the outcome promptly overset the diagnosis. The 
man talked with ward-mates, and particularly with another 
patient who also talked about thought transference. This 
shook the man in his convictions, and he decided that it was 
but imagination and delirium. 

He now told his story: How it seemed that he had in his 
thoughts the phrase, " Sleep, you must sleep; " how he had 
gotten up, saying, "No; "had noticed the others paying no 
attention to him; had gone back to his work and from that 
moment had begun to go into delirium. During this de- 
lirium or delusional state, his whole life from birth up, came 
back to him, as if some one were telling him. The head- 
aches, which he at first felt due to Hertzian waves, suddenly 
ceased. 

Shortly, however, a new phase had set in, in which he felt 
himself surrounded by spies and that others had control of 
his thoughts and were reading them. In fact, he grew a 



63O THE DIAGNOSIS OF SHELL-SHOCK 

little proud of the fact that people reading newspapers all 
around him were actually reading his own thoughts. The 
letters he wrote were being dictated. May 9, he spent a 
night with a succession of nightmares, and woke up with the 
firm purpose of going back to Paris by motor cycle to find 
the spies. He described his fugue and the thousand ideas he 
had on the way, his arrest, his imprisonment in a cell of 
Hertzian waves with a smell of sulphur and poisoned bread 
— a necessary fate on account of the spies. 

On arrival at hospital, he had not known what was going 
forward. The nurses were giving him milk to destroy the 
taste of sulphur; the delirium then grew less and less. The 
room-mates were neutrals, war- weary; he seemed to be read- 
ing the newspapers before his mates, and they seemed to be 
talking of thought transference. May 20, the ward was 
changed. The new ward- mates did not believe in thought 
transference and laughed, causing the man to doubt. 

June 2, the cure was in full process, and the ward was 
changed again; but in the new ward was a patient who had 
the same ideas of thought transference as the patient. At 
this time, the man's autocritique saw through the delusion. 
He talked with his telepathic comrade and pretended to en- 
gage in a fake conversation about it. The delusions shortly 
disappeared, having lasted about six weeks. 



THE DIAGNOSIS OF SHELL-SHOCK 63 1 

/ 
L 



Ordinary gunner's life ; a few days' feeling of moral 
and physical discomfort: Obsession leading to 
fugue. 



Case 445. (Mallet, July, 1917.) 

An artilleryman, 32, gave himself up a few kilometers 
back of the lines, three days after deserting his post. The 
man was a very good gunner and had never been punished 
once. Moreover, the battery was not under any special 
bombardment, and he had been in the same place a number 
of weeks. 

He explained that he had gotten tired during the last few 
days. Everything was well at home and in the regiment, 
but he felt sad, his head felt bad, and he couldn't sleep. 
Something drew him to leave, but then "sang froid came 
back to me, and I gave myself up." He had lived the three 
days without eating and without sleeping. He was very 
emotional over what he had done, but he began to work and 
asked that he be sent back. 

His mother had been very nervous. There was a marked 
facial asymmetry and faulty arrangement of teeth. The 
man was not alcoholic. 

According to Mallet, in these cases of fugue, and in other 
cases of absolute delirium of apparently sudden onset, there 
is a feeling of moral and physical discomfort for some days 
before the outbreak. The outbreak itself is sudden on the 
occasion of some idea, either an obsession or a hallucination. 
Of all the prodromal signs, headache is the most striking. 
According to Mallet, such fugues are the expression of a 
mental imbalance allied to the onirism of Regis. 



632 THE DIAGNOSIS OF SHELL-SHOCK 



Aprosexia and bird-like movements. 



Case 446. (Chavigny, October, 1915.) 

A soldier of the dragoons, 25, entered Chavigny's service 
May 30, 1 91 5. He acted like a mechanical figure, requiring 
guidance. The face was without expression except for the 
mobile eyes, and sudden bird-like movements of the head, 
continually attracted to new noises and objects. An inter- 
locutor was glanced at but not responded to. If an intense 
electrical shock was passed through his abdomen, for ex- 
ample, the man would look for a moment in that direction, 
but only the most fugitive defence reaction would be made, 
and the stimulus could be repeated with the same result, a 
moment later. 

After three days, this aprosexia began to clear, and in four 
or five days, answers to questions and ordinary associations 
set in. Memory reappeared. It seems that he had been in 
concealment in the loft of a barn, when he saw his com- 
manding officer carried by, having lost an arm and a leg. 
He lost consciousness and fell three meters, through the trap- 
door of the loft. There was thus a combination of trauma 
and emotional shock. No external lesion was produced in 
the fall. His memory showed a very sharply defined gap for 
the period of his aprosexia with the bird-like movements, of 
eight days, and his memory was perfectly good up to the 
time of the fall. This is one of five cases observed by Cha- 
vigny, who remarks that there is something in the attitude 
of the young child which recalls the aprosexia of these pa- 
tients. (Perhaps the phrase of James, " buzzing, blooming 
confusion" might be used.) One must go back to a period 
in the child's development when he is not yet able to smile 
or keep his glance fixed on a shining object. On the whole, 
the resemblance is closer to the attitude of certain caged birds. 

Re aprosexia and bird-like movements, see discussion under 
Case 353. See also Case 334. 



THE DIAGNOSIS OF SHELL-SHOCK 633 



Shell-shock ; unconsciousness (45 days) : Mutism 
(monosymptomatic) . 



Case 447. (Liebault, 1916.) 

A soldier, 32, had a large caliber shell burst one meter from 
him September 26, 19 15, lost consciousness and remained 
comatose 45 days. He then got progressively better but 
did not recover speech. He was neither blind nor deaf. He 
was examined at the neurological center at Nantes and there 
Mirallie called him a case of hysterical mutism, ^finding no 
paralytic disorder of any sort and finding the patient able 
to write his story, to read and to understand what he read, 
but without much power of retention. He was placed in the 
phonetic reeducation service March 30, but made no prog- 
ress. In the effort to speak the patient made strong gen- 
eralized contractions, including contractions of his face and 
winking of his eyes, contractions of the jaw, and movements 
of the neck muscles. In fact, he seemed to be agitated by a 
sort of cervico-facial tic, and sometimes, although not al- 
ways, he succeeded in getting out a loud voice sound, in 
which one could imagine the syllable that he was trying to 
utter. 

In this case the mutism was evidently secondary to motor 
disorder. It is an example of functional dyskinesia (Benon). 
As long as this functional dyskinesia remains, the patient will 
not speak. The respiratory muscles are disordered, since 
the respiratory capacity does not go over 3 liters. This 
approaches the normal, however, and if the subject cannot 
speak it is because his diaphragm is subject to jerky or 
cramplike movements and because the lips and tongue do 
not execute the proper movements either for sounds, syl- 
lables or words. Such a patient cannot protrude the tongue 
or even bring it beyond the teeth, 



634 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-explosion : Recurrent amnesia. 



Case 448. (Mairet and Pieron, April, 1917.) 
A shock case of Mairet and Pieron had a disorder of mem- 
ory. Association paths were open one day and closed the 
next. Subjected to shell-shock, September 18, 191 5, he was 
found wandering in the woods a few days later, having com- 
pletely lost his memory, even for his name. In November he 
recovered his surname but not his given name. On stimu- 
lation he was gotten to remember his city, his father, the 
street, and the like. Shortly he could get back his mem- 
ories more quickly; after a week it took only 35 seconds to 
remember that he was born at Paris. However, his recollec- 
tion of the Trocadero and of the Eiffel Tower, which had 
come back to him in November, 191 5, was lost again in 
April, 1 91 6, to return once more in August. December, 1915, 
he could not write to dictation, but copied writing as he would 
a design. He suddenly felt himself able to write in the 
Morse code (he was a telegrapher); then ordinary writing 
returned. February, 19 16, however, he had forgotten what 
the Morse code was. In April, he was taught numbers. 
One day he would know left from right, but had forgotten it 
by evening. 



THE DIAGNOSIS OF SHELL-SHOCK 635 



^ 



Shell-explosion : Comrade killed : Amnesia. 



Case 449. (Gaupp, April, 191 5.) 

F. K., a 23-year old soldier, in civil life a turner, of Polish 
descent, and of a somewhat nervous and easily excitable dis- 
position, early in August went from Strassburg into the 
Vosges and Lorraine. On the 26th a number of shells exploded 
near him. The troop was excited and took refuge in a cellar. 
K.'s best friend was torn to pieces by a shell. When his 
body was removed, K. felt sick and lost consciousness. He 
arrived at the clinic in Tubingen in a stuporous condition, 
by hospital train, on August 31, 1914. He walked weakly to 
his bed, supported by two men, and lay in the bed, apathetic 
and reacting to questions only with a stare. Things put in 
his mouth were swallowed. He remained motionless. 

Next evening he answered a low Yes to a nurse's question 
about eating. A little afterwards he said he supposed he 
was a prisoner in the enemy's country. A little later he got 
properly oriented but still did not know how he had come. 
September 2, however, he was much clearer and said he had 
awakened out of a long dream. There was a complete 
amnesia, however, from the moment when he went to help 
remove the torn body of his friend up to September 1. 
Memories became clearer for the period before the shell ex- 
plosion. The patient became very lively, talking vividly of 
war experiences, imitating shell hissing with an expression 
of intense anxiety, getting accustomed to battle scenes, say- 
ing that he was now seeing everything again as if real. He 
remained anxious for some days, complaining of weight on 
his chest and of feelings of internal restlessness and tension. 

Amnesia for the period of August 26 to September 1 re- 
mained; all that K. could add to the story of those days 
was that he had been thrown sidewise for some distance by 
the air pressure of the shell. 

From September 6 onwards, he grew calmer but he was 
still very labile, given to lively imaginings and emotion. By 
the middle of September he was well and discharged for 
garrison duty. 



636 THE DIAGNOSIS OF SHELL-SHOCK 



Shell-explosion : Recurrent amnesia. 



Case 450. (Mairet and Pieron, July, 1915.) 

A man, 33, had suffered shell-shock early in December, 
1 9 14. His intervening history is not reported, but he 
showed on admission to the service of Mairet and Pieron, 
May 5, 1915, a remarkable amnesia. There was a complete 
cutaneous anesthesia, anosmia, and ageusia, and he was mute. 
He lived only in the specious present. His previous life was 
completely abolished for him. He could dress himself, eat, 
use a fork and spoon, and a glass. He understood ordinary 
words; such words as man, woman, day and night, however 
had no meaning. He was observed for 15 months and pre- 
sented four phases. 

In phase one, there was a measure of success in reeduca- 
tion, such that he grew able to recognize a few persons, to 
find his bed, and name objects. He was got to copy writing, 
to learn the alphabet, and to say a few words. He could not 
write from dictation, however. Less than two seconds after 
looking at an A, he had forgotten how it looked and could 
not trace it. This first phase lasted about two months. 

The second phase began with fatigue, headaches, and the 
rather quick effacement of all he had relearned. If an 
errand was given him to do, he would run to do it before he 
should forget it; but if the trip required more than 4 or 5 
seconds, he had to stop, not knowing what to do with the 
thing in his hands. He was still able to recognize 4 or 5 
persons, but could add no more to his repertoire; and when 
one of them had been absent for a fortnight, he did not 
recognize him on his return. He could not remember the 
time for his meals. 

The third phase was ushered in by improvement after 
vomiting; his speech came back in a feeble voice, Novem- 
ber 16, 11 months after the shock. Reeducation could now 
be undertaken again. He easily relearned a number of 
things, feeling the greatest astonishment at his new acquire- 
ments as to the sun and the moon, the trees and the flowers, 
and the like. He expressed a curiosity to see his own home, 



THE DIAGNOSIS OF SHELL-SHOCK 637 

but when he went thither, he could recognize nothing. He 
wanted to get back home, namely to the hospital where he 
had lived all his life; where, in fact, he had been born from 
the psychic point of view. 

At this time began the fourth phase, April, 19 16 — a 
phase of decline once more, in which a large portion of his 
acquisitions were again lost and he fell back to his condition 
in the second phase. 

See discussion under Case 353 and under Case 367. Re 
confusional mental states, Roussy and Lhermitte, after dis- 
tinguishing stuporous confusion from simple confusion, go 
on to differentiate what they call obtusion (see also dis- 
cussion under Case 353). These authors say that Regis, 
in common with most psychiatrists, fails to distinguish the 
slow thinking and amnesia of true mental confusion from the 
temporal and the spatial disorientation that characterize the 
so-called obtusion. Of course, in all attacks of confusion, 
both attention and memory are affected, but there are spe- 
cial types in which attention defects and memory defects 
stand out in relief. The first of these types is the aprosexic 
type with birdlike movements, described by Chavigny (see 
for an example, Case 446) . This aprosexia may be combined 
with mutism, deafness, or convulsions. The form of con- 
fusional disease in which amnesia is the out-standing feature 
is due to toxic or infectious disease, or is a Korsakow phe- 
nomenon, i.e., in the psychiatry of peace times; but the 
war has brought out amnestic confusion in other states 
than the toxic, infectious, and alcoholic states (Regis, 
Chavigny, Dumas, Roussy and Lhermitte). The amnesia 
may be incomplete, a sort of dysmnesia, or twilight memory, 
but as a rule, the amnesia is lacunar. The toxic and in- 
fectious amnestic confusions have a loss of memory for events 
following the onset, but these war cases of amnestic con- 
fusion have the loss of memory running back far into the 
patient's past, slipping from the mind his name, his parent- 
age, age, and vocation. Instead of being like the toxic con- 
fusional amnesia, an anterograde amnesia of fixation, the 
Shell-shock amnesia is apt to be antero-retrograde. These 
antero-retrograde amnesias, whether due to emotion or to 



638 THE DIAGNOSIS OF SHELL-SHOCK 

strong physical shock, may sometimes leave in sharp relief 
the recollection of the shock or event itself which initiated 
the amnesia. Meanwhile the patient does not forget auto- 
matic actions of dressing, reading, writing, and the like. 
The amnesia may be very selective, imitating aphasia, word 
blindness, letter blindness, agraphia, and the like. All this 
is part of the hallucinatory form of mental confusion which 
Regis describes as oniric delirium (see for oniric delirium, 
discussion under Case 333). 

Lepine distinguishes amongst the confusions, five forms as 
follows: Simple confusion, hallucinatory confusion, acute 
delirium, stuporous confusion (under which Lepine also con- 
siders the battle hypnosis of Milian, see Case 365, and 
Roussy's narcolepsy), and amnestic confusion. All these 
phenomena from the clinical point of view are connected 
with an acute and fleeting insufficiency of the most delicate 
or, as it were, psychic portions of the cerebral cortex, the 
delirium, so to speak, being activity of the unconscious, 
whereas a confusion is due to a clouding of the centre O of 
Grasset's polygon. 



THE DIAGNOSIS OF SHELL-SHOCK 639 



Soldier's heart, both neurotic and organic. 



Case 451. (MacCurdy, July, 1917.) 

A territorial, 19, who had enlisted in January 19 14, reached 
France in September, 19 16. He was of neurotic make-up 
(night terrors, fear of dark, giddiness in high places, fear of 
tunnels, enuresis until 10 years, worry about seminal emis- 
sions), and had always had a tendency to short wind. En- 
listing at 16, he found it hard carrying his pack at first but 
soon grew stronger. The trench life was distasteful. He 
began to wish that he might be killed, or at all events re- 
moved from the trenches. Pains developed under the heart, 
with shortness of breath, palpitation, dizziness, and faint 
feelings. The man connected these heart symptoms with 
what he called his weakness of gall bladder (namely, enuresis) . 
He was several times sent off duty for heart treatment. 
After three months in and out of hospital, he got trench foot, 
was sent to England, and transferred to a special heart hos- 
pital. Here the pulse test was positive, in that the rate did 
not diminish as it normally does after two minutes' rest. 
After graduated exercises for several months, the pulse test 
had become negative and the heart had gradually improved 
from the organic standpoint. The patient, however, in- 
sisted that his heart trouble was as bad as ever, and was 
probably consciously hoping that his symptoms might per- 
sist. 

Re soldier's heart, Abrahams classifies cases that come to 
the military surgeon for heart symptoms as (a) functional 
fatigue cases ; (b) nicotine and drug cases ; (c) organic heart 
disease and Graves' disease; (d) the true soldier's heart, 
occurring in men with a neurasthenic soil that lose control 
of the vasomotors and inhibitors of the heart. 



64O THE DIAGNOSIS OF SHELL-SHOCK 



Soldier's heart, neurotic. 



Case 452. (MacCurdy, July, 1917.) 

An Australian gunner, 35, of a neurotic make-up (night 
terrors; horror of blood; fear of thunderstorms, high places, 
tunnels, horses; shy with both sexes), benefited by military 
training physically, but remained as neurotic as ever. On 
the way to his first service in Egypt, he feared shipwreck, 
and in Egypt was troubled by the weather and occasional 
palpitations and sinking feelings. He was transferred to 
the French front, May, 19 16. He was terrified and de- 
pressed under shell fire, and horrified by blood. Peculiar 
sinking sensations or feelings that the soul was leaving the 
body came to him as he was going off to sleep; from which 
he woke at times with sudden starts. Later he had night- 
mares of things, mainly shells, falling on him. He worried, 
wanted death, and thought of suicide. In May, 191 7, he 
was blown off his feet by a shell. Thereafter he began to 
feel that shells were being especially aimed at him, and four 
days later got a pain in the side, and began to tremble and 
breathe with difficulty, as if his throat were swelled up and 
he were going to choke. He ascribed this to gas. The 
bombardier finally sent him back to a hospital, where he 
grew weaker and screamed aloud on being awakened by his 
dreams. After six weeks in a special heart hospital, all the 
symptoms cleared up except the choking feelings and fear of 
instant death. Organically the man appeared normal. An 
initial pulse of 96 ran up to 168 after exercise, and down to 
84 after two minutes' rest. 

Re soldier's heart, Abrahams speaks of sundry hypotheses 
that he regards as erroneous. Soldier's heart has been 
thought to be (a) athlete's heart; others regard it as (b) a 
toxemic condition, possibly of bacterial origin; (c) hyper- 
thyroidism (a larval form of Graves' disease has been in- 
criminated) ; (d) excessive cigarette smoking; and (e) defi- 
ciency of buffer salts in the^blood, have been proposed by 
other authors. 



THE DIAGNOSIS OF SHELL-SHOCK 64 1 

Gallavardin has especially studied the tachycardial cases 
revealed by the war, cases in which auscultation is frequently 
unable to detect aught. These tachycardiacs are often 
hypertensive. Sedentary service should be found for them. 

Re pulse 168 after exercise, Gallavardin found 8 per cent 
of 500 non-organic and non-tuberculous cases to run up 
from 150 to 175 (125 to 150 in 2*j per cent; 100 to 125 in 
37 per cent; 75 to 100 in 26 per cent; 50 to 75 in 2 per cent). 

Re cardiac neuroses, Brasch points out that cardiac neu- 
roses in the male in war time have found a strange new asso- 
ciation with hyperesthesia of the skin. The patients showed 
dermatographia and hyperreflexia. The hyperesthetic zones 
of Head and Mackenzie were found by Brasch in all cases of 
organic cardiac disease, but also in two cases of cardiac 
neurosis in hysterics. 

Moore calls attention to somewhat similar phenomena in 
the somatic group of nervous and depressed cases found in 
the war. These patients are fatigued, exhausted, sleepless, 
tremulous, vascular, and cardiac cases, with dermatographia, 
areas of paresthesia, and pains in the neighborhood of wound 
scars. 



642 THE DIAGNOSIS OF SHELL-SHOCK 



War Strain; Shell-shock: Hysteria (question of 
malingering). 



Case 453. (Myers, March, 1916.) 

A sergeant, 32, with 11 years' service and eight months' 
service in France, was admitted to a base hospital for inquiry 
as to possible malingering. It seems that he had taught in 
an army school for seven years before the war. He found 
heavy marches in France too much for him and fainted in 
the retreat from Mons and during the fighting on the Aisne, 
where he had reported sick for dysentery. The field am- 
bulance where he was treated was near the shell fire, and a 
shell knocked him into a ditch. The ambulance had to move 
to a cave. Thereafter the patient suffered from tremor when 
spoken to or when watched. After discharge, he was em- 
ployed as a dispatch rider on a motor cycle, but after three 
months lost his nerve for this work and took charge of fatigue 
parties. He found the work too much for him. He had been 
a total abstainer. Finally the malingering charge was 
brought up. 

The patient was nervous, delicate-looking, with widely 
dilated pupils, prominent eyeballs, tremor of right arm, and 
pulse of 102. The tremor was markedly lessened when he was 
alone, and was somewhat under control. He felt that his 
memory was defective, and tests demonstrated the defect. 

In hospital patient slept better, the pupils grew smaller, the 
pulse rate diminished. There was a reduction in sensibility 
to pain over the right side of the head and body and over 
the right limbs. A prick of the right arm or leg was described 
as a finger touch. There was also almost complete hemi- 
anosmia and complete hemi-ageusia on the right side. Visual 
acuity was diminished on the right, and there was general 
limitation of right field; left-sided vision and field normal. 

After a month in hospital at home and two months' leave, 
the patient was discharged no longer physically fit for ser- 
vice. He is now weak physically and mentally, subject to 



THE DIAGNOSIS OF SHELL-SHOCK 643 

severe headaches, and tremulous, especially in the right arm, ! 
when tired. 

Re malingering, Sicard denies the existence of unconscious 
malingerers (presumably regarding this phrase as a figure 
of speech in relation to hysteria), and divides malingering 
into a creative and an acquired form. The simulateur de 
creation assumes attitudes and symptoms to attract atten- 
tion or pity; the simulateur s de fixation having been sick 
in the beginning, perpetuate their disease, in brief, crystal- 
lize their neuroses. The fixateur may be very realistic in 
all this, seeing that he has known from his own experience 
what a real disease is. The formula runs: The simulateur 
de creation improvises ; the simulateur de fixation repeats. 

According to Mott, malingering in the form of an assumed 
Shell-shock is not uncommon amongst soldiers, and is rather 
hard to distinguish from a neurosis developing on the basis 
of an idee fixe. 

Ballet's definition of simulation is "a subjective or objec- 
tive disorder which the patient invents with the idea of 
voluntarily and consciously misleading the observer." 
Closely related to simulation is exaggeration or prolonga- 
tion, conscious or intentional, of a real disorder. Babinski 
states that cases of genuine simulation are very rare, and 
that the subject under suspicion should be given the benefit 
of the doubt. Especially the word simulation, or similar 
words, should not be uttered in the presence of the patient. 
Practically speaking, psychotherapy applied as in cases of 
hysteria may often cure the simulator and the exaggerator. 



644 THE DIAGNOSIS OF SHELL-SHOCK 



The officer who could not kick. 



Case 454. (Mills, January, 1917.) 

An officer had had a bullet in the right calf, of which 
nothing was evident months later but small scars of entrance 
and exit. Nevertheless he complained of pain, especially 
after walking, and of inability to dorsiflex the foot beyond 
a certain point. No wasting could be found and no impair- 
ment of sensation. The muscles were faradically normal. 
Mills thought the symptoms were exaggerated and so re- 
marked to the officer. 

Under anesthesia, however, the dorsiflexion also proved 
to be impossible, and after exerting considerable force, 
Dr. Dunhill was able to rupture a massive fibrous band of ad- 
hesions that had prevented extension. The officer made a 
good recovery. 

Dr. Mills confessed his error to the officer who had naturally 
resented the suggestion of malingering. The officer forgave 
him. 

Re malingering, Moore states that no diagnosis of malin- 
gering should be made without the most careful examina- 
tion and consideration of the individual as such, on account 
of the fact that the erroneous diagnosis dejects the patient 
and postpones recovery. It is particularly unwise to term 
the trouble " imaginary," or to talk about "suggestion" or 
use similar terms in the presence of the patient. 

Craig has found very few cases of actual malingering and 
states that tremors and paroxysms are often mistaken there- 
for. Bispham remarks that few malingerers are found among 
the patients of a doctor who is known to be a thorough 
examiner. 

Re orthopedic cases like Case 454, Gleboff remarks upon 
the simulation of joint affections and upon methods of sur- 
prising the malingerers into sudden movements made in obe- 
dience to request in the course of medical examination. 



THE DIAGNOSIS OF SHELL-SHOCK 645 



Doubtful accounts by patient concerning arm pal- 
sy : Incorrect diagnosis of simulation. 



Case 455. (Voss, November, 1916.) 

A volunteer, 18, just before the war had a fall in which 
apparently he injured his skull. In December, 1914, he hurt 
his left forearm. About this injury he sometimes said he 
fell in a storming attack in a trench and broke his arm, and 
again he said his arm had been smashed by stones from a 
falling house. From that time forward there was paralysis 
of the left forearm with flexor contracture. May, 191 5, 
slight hypesthesia could be demonstrated on the ulnar side 
of the arm, suggesting ulnaris injury. There were, however, 
no considerable electrical changes. 

Six months later the man was sent up with a suspicion of 
simulation. In the meantime the contracture had resolved 
and there was a typical hysterical paralysis with all signs of 
neurosis. Six months later he was well enough to be ex- 
amined for military service. 

Here was a case in which the incorrect data offered by the 
patient himself as to the origin of his paralysis gave rise to 
the suspicion of simulation, whereas, as a matter of fact, the 
man was clearly hysterical. 

Re incorrect data supplied by the patient to his own dis- 
advantage, Lumsden remarks on the great difficulty of diag- 
nosis in cases where hysteria and malingering have been 
combined, and Morselli states that, if the doctor has really 
made up his mind that the man is shamming, he should send 
him back to the fighting line at once. 



646 THE DIAGNOSIS OF SHELL-SHOCK 



Forearm wound : Hysterical edema? 



Case 456. (Lebar, July, 1915.) 

A corporal, 26, formerly a farmer, was struck in the 
forearm by a shell fragment on the mid-portion of the radial 
border. The wound was slight (the fragment entering and 
emerging hardly 2 cm. apart) but bled profusely, according 
to the patient, who was evacuated next day but one to a 
hospital in the interior. By this time the right hand was 
swollen, nor could any movement of hand or fingers be made. 
Massage, mechanotherapy, passive movements did no good. I 

The man entered the neurological center of the Eighth 
Region, July 7, 1915, when there were already a few skin 
changes with dorsal thinning and palmar thickening. There 
was cutaneous anesthesia not only of hand and fingers but of 
the forearm to the elbow, and this anesthesia included heat 
and cold. Position sense was preserved. There was no 
evidence of atrophy except for the skin changes. An elec- 
trical examination showed normal conditions. 

July 13, a sealed bandage was put on, but at the end of 
five days the hand looked as before. July 19, a new treat- 
ment was announced to the patient. With a hot needle a 
number of pricks were made on the dorsal surface of the 
hand and a few c.c. of fluid were withdrawn (containing a 
slight amount of albumin and a few lymphocytes), whereupon 
a dry bandage was put on. The next day a few finger and 
thumb flexion movements could be made and sensation had 
returned. Sensation completely returned July 21. The 
flexion movements were still incomplete, by reason of the 
edema and dryness of the skin. However, July 22, flexion 
was better and the swelling had gone down sixty per cent. 
Jacquet's biokinetic treatment (active gymnastics of the 
hand and fingers) was given for four hours. July 25, the 
edema had greatly diminished and normal motion had re- 
turned. 

Examination excluded renal disease. There was no sign 
indicating phlegmon. Quincke's disease had other features. 



THE DIAGNOSIS OF SHELL-SHOCK 647 

Fraudulent application of a bandage might be considered, 
but the course of the disease under sealed conditions seems 
to exclude this hypothesis also. May it, therefore, not be a 
case of hysterical edema? 

Re hysterical edema, see remarks under Case 407. In 
the case above, of Lebar, Babinski calls attention to the 
fact that the edema and the contracture diminished though 
they did not entirely disappear after the scarifications. This 
physical treatment did not act, according to Babinski, wholly 
as a matter of suggestion, and he fears that some cases of 
so-called hysterical edema are really cases of physiopathic 
vasomotor disorder; in fact, three of the cases published 
(and amongst them, the present case of Lebar), were cases 
of edema associated with contracture and developing in an 
injured limb. To prove a case of anything to be hysterical 
is, of course, according to the Babinski school, to submit it 
to a therapeutic test and cure it by suggestion. 



648 THE DIAGNOSIS OF SHELL-SHOCK 



Shell splinters in head : Suspicion of (a) simulation, 
(b) hysteria. Case actually surgical. 



Case 457. (Voss, November, 1916.) 

A man, injured by shell fragments in the head and sus- 
taining fracture of both arms and a thigh, got well of his 
wounds, but fell into a nervous state with headache and 
dizziness. He was given prolonged observation psychiat- 
rically and then sent back to the front as fit for service, but 
was shortly returned to hospital and sent to Cologne under 
the suspicion of simulation. 

The picture was of unilateral increase of tendon reflexes, 
accelerated pulse, disorder in the intake of ideas, difficulty in 
finding words and delayed associations. His gait suggested 
a psychogenic disorder. X-ray showed two shell fragments 
in the vault of the skull. 

According to Voss, it is a sad fact that victims of skull 
injuries are frequently charged with simulation or exagger- 
ation. J In the above instance, moreover, this charge was 
undoubtedly inaccurate. 

Re simulation, see remarks under Case 453. Re neuro- 
logical cases, the Neurological Society of Paris sent to the 
War Ministry a special note pointing out how tardy was 
the reference of sundry neurological cases to the special 
neurological service. They pointed out how important it 
was to send to these special services all cases of bullet and 
shrapnel lesions. 

Re the malingering question, there is a wide divergence of 
opinion, even amongst experienced workers in the same city. 
The late Professor Dejerine said he had not seen a single 
case of malingering. In fact, he thought that malingering 
amongst soldiers and amongst injured industrial workers had 
been much exaggerated. Marie, however, working in the 
examination of many surgical cases, found malingering rela- 
tively common. Amongst forty of his cases, he regarded 
at least nine as malingerers or exaggerators. 



THE DIAGNOSIS OF SHELL-SHOCK 649 



" Sciatica," torticollis, stiff arm: The desire to 
avoid active service plus functional disease. 



Case 458. (Collie, January, 1916.) 

A man enlisted September, 1914, went to France after six 
months' training, immediately put himself on sick list, and 
was admitted to a base hospital : Diagnosis, sciatica. Later, 
he ceased complaining of sciatica and developed spastic torti- 
collis. He was sent back to England, was treated with 
radiant heat and so on, and was eventually sent to the Royal 
Bath Hospital at Harrowgate. 

He recovered from torticollis after six weeks' treatment; 
but then developed a spasmodic contracture of the right 
shoulder and forearm. He was massaged for this and also 
given high frequency treatment. Then came two transfers 
(massage). 

Early in December, 1915, he came under Collie's obser- 
vation. He then showed right wrist bent at right angles to 
the forearm; hand tightly clenched, so firmly that it seemed 
as if the wrist were ankylosed. The case was obviously a 
functional one. The man refused to enter hospital at Collie's 
suggestion. He was sent to the Maida Vale Hospital. Pre- 
viously he tried to persuade the medical officer that further 
hospital treatment was unnecessary, stating that he was 
now able to straighten his arm and that he was applying a 
splint to keep it straight. He progressed slowly in the in- 
stitution. Told, if he would recover within fourteen days, he 
would be classified "for home service only" — before the 
fourteen days were up, he had suspended his weight on a 
trapeze and pulled himself up to his chin on it; had also 
lifted a 28-lb. weight with his paralyzed hand. In short, he 
wholly recovered. He is now doing duty with his unit. 

Collie says this is not deliberate malingering but a mix- 
ture of functional disease and an obvious desire to avoid 
active service. When he appeared before the board for a 
final decision, there was a tendency to assume the old 



650 THE DIAGNOSIS OF SHELL-SHOCK 

paralyzed position until he was sharply called to order, when 
his arm assumed normal position. 

Conclusion : The direct personal treatment of his mental 
condition and an appeal to his lower instincts were imme- 
diately curative and of much more value than the radiant 
heat or high frequency treatment. 

Re Collie's case, Russel finds surprisingly large numbers of 
malingerers; he found many at the time of the battles at 
Loos. It was particularly easy in cases of epilepsy to dem- 
onstrate a close relation between hysteria and malingering. 
In the psychogenesis of these conditions, Russel emphasizes 
the initial element of deception, which soon enormously in- 
creases either through the patient's convictions of his ability 
to deceive or through a process of autosuggestion. Cases of 
semi-malingering are not uncommon. In England, Russel 
found more cases of a clearly psychogenic nature; yet in 
these, also, there was always primarily an element of decep- 
tion. 



THE DIAGNOSIS OF SHELL-SHOCK 65 1 



Yes-No test of value re anesthesia. 



Case 459. (Mills, January, 1917O 

The "Yes- No " test proved of special value in the case of 
an Australian private. Shortly after landing at Gallipoli 
this man had a bullet graze his ankle and fell some thirty feet 
over the bow of a ridge. He was picked up unable to move 
his legs and insensitive therein. 

The paraplegia and anesthesia lasted three months. 
" Fracture dislocation of the dorsal spine " was the diagnosis 
made, and laminectomy was even contemplated. The 
sphincter reflex was normal and there was no atrophy, no 
rigidity and no reflex disorder. Asked to say " no " when he 
could not feel a pin-prick and " yes " when he did feel it, he 
replied " no " to each prick to the anesthetic area and changed 
his reply to " yes " when the sensitive parts of the body were 
examined. At another time the answers were found not to 
correspond with those given before. 

The soldier was assured that he would get well and that 
as soon as he could walk he would be boarded and returned to 
Australia. 

After a number of weeks he became able to walk. 



Arabian fever. 



Case 460. (Roussy, April, 191 5.) 

An Arab fell on his knee, one day in the trenches. A con- 
tracture of the left arm, with great pain, and a temperature of 
38 to 40 degrees, with hemoptysis, developed. This man had 
been considered tuberculous. One day, however, the ther- 
mometer went up to 41 degrees. It was discovered that he 
took artificial means to push the mercury up, and that the 
spitting of blood was voluntary. All these phenomena dis- 
appeared after he was put in the guardhouse for 24 hours. 



652 THE DIAGNOSIS OF SHELL-SHOCK 



Shrapnel scratch of head: Hysterical amaurosis 
" ? " On isolation in a dark room, the patient began 
to see light ! 



Case 461. (Briand and Kalt, February, 191 7.) 

A man may seek to exaggerate an anomaly of his eye which 
had existed before the war, in order to live comfortably far 
from the front. 

A soldier sustained a slight scratch from a shrapnel bullet 
in front of the left ear, which scarred over in a few days. 
The soldier said, however, that the bullet had gone through 
his skull and a few hours after his wound said he could not 
see. Sent to the hospital he continued to say he was blind 
and finally brought up in an asylum for the blind near Lyons 
where he was taught to cane chairs and to write in Braille. 
This happened in July, 191 5. 

In October he was sent to the Hospital at Quinze-Vingt 
where a diagnosis of hysterical amaurosis was made with a 
large interrogation point. He was then sent to Brequet 
where there was a section reserved for disciplinary cases and 
very nervous cases not wanting to get well, a service under 
the charge of Roubino witch. 

The soldier escaped with a comrade and eventually reached 
Val-de-Grace where the diagnosis of hysterical amaurosis 
was again made. Examinations several times showed that 
there was nothing abnormal about the eyes except that the 
eyelids presented habitual fibrillary movements (antebellum). 

The eyelids passively opened, would remain open for a few 
minutes and then close. There was no winking of the eye to 
a light, yet the pupil preserved its reflex power. 

Vision was abolished, however, the soldier said. He was 
without any other motor or sensory disorder. Much sym- 
pathy was given to the poor blind soldier. People were 
much astonished when the chief of the ophthalmological ser- 
vice had the man isolated in a dark room. Three weeks 
later the man had begun to see the light a little. A week later 



THE DIAGNOSIS OF SHELL-SHOCK 653 

c 

the eyes remained open without the necessity of having the 
lids raised by the fingers, and vision returned. 

Re amaurosis, Parsons explains the blindness which may 
remain after consciousness returns following Shell-shock, as 
a condition in which the lower visual paths are carrying on 
their functions normally. For example, the pupillary reac- 
tions are preserved. The condition is not unlike that found 
in amaurosis of uremia, and Parsons has found it in children 
with posterior basic meningitis. For Parsons, therefore, the 
block occurs in the higher centers above the thalamus, possibly 
in the synapses of the optic radiation fibers. Ormond states 
that the true cases of concussion blindness invariably pass 
through phases of great discomfort; whereas the malin- 
gerers are without such discomfort. Medical suggestion, also, 
has a powerful effect here, and may actually retard recovery. 



654 THE DIAGNOSIS OF SHELL-SHOCK 



A newspaper cure. 



Case 462. (Sicard, October, 1915.) 

Sicard read in a French newspaper a story to the effect 
that, at two o'clock in the afternoon, a soldier had fallen 
on the sidewalk between Nos. 40 and 42 Boulevard de Liberte, 
in a nervous crisis. The people ran and picked him up. 
When he came to, he was very joyful, perceiving that the 
shock had given him back his speech, which he had lost the 
August previous. This soldier, the newspaper continued, 
became deafmute through the explosion of a bomb in a fight 
in Upper Alsace. " The brave soldier is most happy over 
the unexpected result." The newspaper went on, " We con- 
gratulate him sincerely, as well as the people who assisted 
him." He was the more contented that he had gotten well 
because, the soldier said, he would now be able to go back 
among his comrades to fight with the Boches! 

Now, in point of fact, Sicard had dealt with this soldier 
the morning of the day in question. He had been simu- 
lating mutism for ten months, and finally told Sicard that 
he would like to leave that afternoon as he felt cure coming. 
Sometime after, he wrote a letter of profuse thanks for the 
benefits received, and said he did not deserve to avoid court- 
martial. He also said that he was going to do everything 
he could to justify himself. Incidentally, he kept his word 
and an officer in his regiment later gave him an enthusiastic 
recommendation. 

Re malingering, see discussion concerning simulateurs de 
creation and simulateurs de fixation under Case 453. 



THE DIAGNOSIS OF SHELL-SHOCK 655 



Deaf mutism : Explained by patient as malingering. 



Case 463. (Myers, September, 191 6.) 

A pure malingerer, of set purpose, initiates a quasipatho- 
logical condition which he will discard when he has gained his 
end or when he is assured that he is unobserved. Malinger- 
ing in the field of speech is rare. A private, 26, one year in 
service, three months in France, entered a base hospital, 
deaf mute for nine weeks. He wrote: " I should be very 
happy if you can do anything for me. I cannot give a very 
clear account of what happened, as it is sometime since. 

I remember retiring from Hill with some more to some 

trenches, and in the open we were shelled and I lost touch 
with our chaps or else they were killed. I remember a great 
concussion and finding myself on the ground, and a soldier 
dragged me up and we ran for the trench. I was very thirsty 
and I ran down the trench to get some water. I met one of 
our chaps and tried to ask him for some, and I could not 
make him understand. He only smiled at me. The man who 
picked me up took me to an officer who was sitting on the edge 
of the trench and tried to make me understand, and then 
he sent me with this man to a dressing station, and from there 
I have been to different places, the names of which I do not 
know, except the last place, No. — Convalescent Camp. 
I have been there about two months " 

He seemed anxious to get well. He could not understand 
what was said. Induced anesthesia caused no phase of 
excitement, and the patient failed to regain his speech. 
He was evacuated to England. Three months later the 
patient thence wrote the following confidential letter from a 
Convalescent Home. " Sir, — I regret very much to inform 

you that I was imposing upon you. 1 may state that I 

was physically unfit for the Front. During the whole 

time of training my pay was chiefly spent in tonics and drugs, 
but I kept going as I was determined to see what it was like 

at the Front. I have written this that your 'notes' 

on cases will not suffer any detrimental effect through my 



656 THE DIAGNOSIS OF SHELL-SHOCK 

imposture. I have not got my discharge yet, but shall 

stick out for it. I ' speak ' but do not ' hear ' very well. — " 
He was in two hospitals for functional nervous disorders in 
England, but in neither institution was he regarded as a 
malingerer. 

Re hysteria explained by the patient as malingering, 
Chavigny discusses what he calls sur simulation. The physi- 
cian must not fall into a permanent state of suspicion, 
and especially must not reveal his suspicions to the accused 
or to the bystanders. Chavigny quotes a French soldier 
whose letter to his wife was intercepted, stating that he was 
going to feign deafmutism to secure his discharge. Before 
he had succeeded in doing so, however, he suffered Shell- 
shock, and got a true hysterical deafmutism, which showed 
no signs of malingering whatever. 



THE DIAGNOSIS OF SHELL-SHOCK 657 



Deafmutism : Appearance of malingering. 



Case 464. (Myers, September, 1916.) 

A stretcher bearer was seen by Lt.-Col. Myers two days 
after admission to a base hospital. Stolid looking and mute, 
he had nevertheless talked in his sleep, had written a few 
words about " shells coming over," and understood what was 
said to him. Lt.-Col. Myers' notes run, " He puts out his 
tongue and closes his eyes and holds out one hand when I 
ask him to do so, but gets stupid (as if sulky) when I ask for 
the other hand. He will not hear any more. Next day 
quite deaf, and the following day light anesthesia with ether 
caused a return of hearing and of speech, with repetition of 
syllables to request on the way to deeper anesthesia. On 
awaking he cried as he was induced to resume his speech, and 
complained of pains in the head. 

11 Two days later, he seemed normal and said that he could 
have spoken on the second day, but that his eyes and ears had 
begun to swim, that he had felt dizzy, and was afraid to talk. 
He did not want to be sent back to the trenches. There had 
been severe shelling. He had lost consciousness until he 
awoke in a hospital at Y — . He recalled, little by little, 
how he had been taken back by a corporal to a cellar. He 
said he wanted to go back, but wanted a rest first. He went 
back to his unit and was reported as having done well for 
four months." 

There was a certain suggestion of malingering about the 
admission of the lad that he could have spoken before he 
was induced to do so. According to Lt.-Col. Myers, a num- 
ber of patients upon recovery of speech are apt falsely to 
believe that they have been malingering. Functional dis- 
orders may simulate malingering. 

Lannois and Chavanne warn against the suggestions given 
to malingerers and to hysterics by the statements on the 
tickets of admission borne by the patients for transfer, 
e.g. "incurable deafness." These authors found 11 per cent 
malingerers amongst 262 cases of labyrinthine shock. 



658 THE DIAGNOSIS OF SHELL-SHOCK 



Simulation of deafmutism. 



Case 465. (Gradenigo, March, 1917.) 

A soldier in the mountain artillery acted like a deafmute. 
He was unable to read or write. It was reported that he had 
been wounded, but no evidence of wound could be found. 
The man had a low forehead and a furtive glance, his whole 
impression being that of a criminal. 

The only evidence of disease found was inflammation with 
perforation of the tympanic membrane of the left ear. Deep 
in the left auditory meatus was found a grain of crushed oats! 
The man's speech difficulty was of a stuttering nature, but 
he stuttered in a different way at every test. He was un- 
willing to be narcotized. Finally by a process of scolding and 
cajoling, the man was made to confess that he could both 
hear and speak well. The peculiar stuttering early led to 
the diagnosis of simulation, but the fact that the tympanic 
membrane was not anesthetic, and that there was no anes- 
thetic zone in the body strengthened the suspicion — to say 
nothing of the refusal of narcosis and the general behavior of 
the somewhat criminal-looking soldier. 



THE DIAGNOSIS OF SHELL-SHOCK 659 



A lame rascal. 



Case 466. (Gilles, April, 1917.) 

An infantryman, 28, had an equino varus, for which he was 
evacuated, hospitalized, given treatment, sent home for 
convalescence, and declared unfit for service. He was, 
however, sent back to the front, and on arrival, went lame; 
whereupon the regimental surgeon sent him to a nerve center. 
The equino varus was there but it was nothing but a simple 
contracture without pain, atrophy, sensory, reflex, electrical, 
or X-ray disorders. 

The abductor muscles were stimulated by electricity and 
the foot straightened. He was kept under observation for 
a time, was lame no longer, and was sent back to his regiment. 

However, sometime later he was evacuated again to the 
same neurological center, stating that he did not know why. 
There was no longer any varus or anything abnormal. The 
rascal had enjoyed the game of going lame and had pre- 
vailed upon his officers to evacuate him. He then saw that 
he was found out and pretended that he had been forcibly 
evacuated. 



660 THE DIAGNOSIS OF SHELL-SHOCK 



Mother love and jaundice. 



Case 467. (Briand and Haury, January, 1916.) 
A soldier, 19 J, entered the central psychiatric service at 
Val-de-Grace, having been evacuated from a hospital in 
Paris, suspect of having brought about a picric acid jaundice. 
He had been undergoing treatment in this hospital, when 
the physician who had isolated him found that he was get- 
ting picric acid in packages secreted in his kepi. 

It seems that the soldier lived with his mother, and en- 
listed when he was not yet 18. He proved to be as good a 
soldier as he was workman, and came through the campaign 
without wound or disease. Accordingly, in December, 191 5, 
he got a six-day leave. His mother, who loved him well, 
and of whom he was the sole support, had much regretted his 
enlisting. She was sick with some stomach disease and, after 
he enlisted, she told everybody that she was going to die and 
that it was his fault. So, when he came on leave the next 
day, she asked him to take a powder so he might stay a fort- 
night. She did not tell him the name of the drug; only told 
him how to take it in a small paper, swallowing it with a 
little water. She said he would become yellow and that he 
would get a supplementary leave. Three days after his 
return to the front, the boy took three of the ten powders; 
took the same number three or four days later; and the others 
five or six days later. He soon had jaundice with colic and 
diarrhea, and apparently was exempted from service for a 
few days. He had returned to the front hardly a month 
when his mother died and the boy got another six-day leave 
for the funeral. He took ten fresh doses of picric acid while 
at Paris, and was put into hospital by a physician without 
suspicion. His relatives thought he was suffering from a 
recurrent jaundice. When the story was told, the boy con- 
fessed to the family, and said that he had taken the drug in 
the first place only to please his mother. It is harder to 
explain the second trial, since he talked about the compassion 
and sense of obedience he felt to his dead mother. It is 
probable that he simply wanted a prolonged leave at Paris. 



THE DIAGNOSIS OF SHELL-SHOCK 66 1 

Re malingering, Blum speaks of fictitious jaundice as hav- 
ing received the name of La Carotte (the carrot) from the 
soldiers. Blum gives a partial list of instances of simula- 
tion as follows: 

SIMULATION 
(Blum, December, 1916) 

False angina, from irritating solution. 

Gastric disorder. Oil and tobacco (with tachycardia or 
jaundice) (use ipecac). 

Diarrhea. (Isolate.) 

Diarrheal stools imitated by a mixture of urine and 
water. 

Dysenteric stools imitated by the addition of fat pork and 
bits of raw meat. 

Appendicitis. Complaint of pain at the well-known Mc- 
Burney point. 

Tape worm. Carriers supply others. 

Jaundice. (Smoke mixture of antipyrin and tobacco; 
drink tobacco juice. Ingest picric acid.) 

Hemoptysis. Irritation of throat surfaces with a needle. 

Albuminuria. Eat kitchen salt to excess in a bowl of 
milk. Edema and albumin disappear on surveillance. Al- 
bumin injected into bladder. 

Diabetes. Phloridzin, or oxalate of ammonia. Glucose 
added to urine. 

Incontinence. (Difficult to prove fraudulent. True in- 
continence in middle of night. Simulated, just before wak- 
ing.) 

Skin diseases: 

Erythema. Herbs. 

Eruptions. Mercury, arsenic, iodine, bromide. 
Herpes. Euphorbiacae. 

Eczema. Rubbing with slightly warmed thapsia. Rub- 
bing excoriated skin with acids, Croton oil, bark of garou, 
sulphur, oil of cade, mercurial pomade. 



662 THE DIAGNOSIS OF SHELL-SHOCK 

Impetigo. With cantharides plaster and pomade stibiee. 

Intertrigo. (In the infantry.) 

Hyperidrosis of feet. Prolonged hot baths. Hot foot 
baths with excoriation, followed by scratching and covering 
with linen soaked in urine. 

Edema of legs. Constriction. 

(In Lombardy, cases due to introduction of equisetum 
arvense, an astringent herb, by fingers and toes, followed by 
energetic rubbing.) 

Recurrent wounds. (Cover with wax sealed bandages.) 

Abscesses. Introduction of septic material. A thread 
soiled with tartar from teeth is drawn through the skin. 
Characteristic odor of resulting abscess. 

Phlegmons. Subcutaneous introduction of turpentine or 
petrol. 

Paraffine tumors. (Apply heat.) 

Sprain. A stopper is put under the heel ; or compress the 
leg with bandages to stop circulation and knock below re- 
peatedly and forcibly. Edema and ecchymosis follow. 

Conjunctivitis. Ipecac, pepper, septic or fecal materials. 
Pupillary dilatation has been produced by introduction of a 
belladonna grain under the eyelid daily. 

Ears. Running at the ears produced by placing urine or 
chemical product in the ear. 

Emaciation and pallor. Ingestion of a large amount of 
vinegar. Abuse of strong tobacco. 

Muscular weakness. Arsenious acid in eggs. Voluntary 
lead and mercurial intoxications. 

Epilepsy. Absence of pupillary reflex to light and pupil- 
lary dilatation, insensibility of nasal mucosa and modifica- 
tions of pulse persistent after the attack is over cannot be 
imitated. 

Fever. Striking elbows against walls to elevate the mer- 
cury in the thermometer. Take temperature by rectum. 

Bites. One simulator had a fork with twisted teeth to 
produce the effect. 

Intra-abdominal projectiles. Bullet swallowed. 



THE DIAGNOSIS OF SHELL-SHOCK 663 



Swelling of hand and forearm, seven months. 



Case 468. (Leri and Roger, September, 191 5.) 

A soldier was wounded September 22, 19 14, at Charleroi 
by a bullet in the forearm. He came under observation 
May 14, 1915, with a huge edema of forearm and hand, 
suddenly stopping at the elbow, an elastic edema, especially 
marked in the palm, which was restored to its smooth contour 
very quickly after being compressed by the fingers, and very 
like an elephantiasis. The hand was in a position of moderate 
extension on the forearm, with fist clenched. There was a 
linear ecchymotic line at the upper edge of the zone of edema, 
especially on the antero-internal face. 

According to the soldier's own story, the swelling had be- 
gun a fortnight after the injury. He said that a very tight 
moist dressing had been applied during the first few days. 

The patient was cared for by massage, and then by local 
baths. He was anesthetized in December and several drains 
were inserted; no result. In January he was chloroformed 
again and two long incisions were made along the internal 
border of the supinator longus and along the ulnar border of 
the forearm. He was better for two weeks after this second 
operation, but then grew worse. 

The diagnosis of syringomyelia was now made, based upon 
the appearance of the arm and upon some ill-defined hypes- 
thesia. This diagnosis was not entertained by Leri and 
Roger who, when they obtained the patient, put him into a 
plaster cast up to the shoulder. The edema went down 
rapidly to normal. In short, it was here a question of a 
simulator, who was even willing to undergo surgical operations 
with general anesthesia. 

Re evading service, GlebofFs classification is as follows: 
I. False assertion of disease of (a) internal organs, (b) vis- 
ion, (c) hearing, (d) joints. 2. Simulation of temporary 
disease of organs. 3. Mutilation of limbs. 

Re swelling of hand and forearm, see remarks on hysterical 
edema under Cases 407 and 456. 



664 THE DIAGNOSIS OF SHELL-SHOCK 



A German shell-shy. 



Case 469. (Gaupp, April, 191 5.) 

Gaupp's simulator had not been under shell fire. He said 
to his captain that he wanted to see his badly wounded 
brother (he had in fact no brother), and got a furlough on 
this ground. He then fled as far as possible from the front, 
into the interior, roved about for some days, falsely asserting 
that he was under dentist's treatment. 

He was brought to Tubingen on the ground of mental 
derangement, on a hospital train, and was delivered to the 
clinic as a case of Shell-shock. This man's state of excite- 
ment soon ended. As Gaupp could not make out his case 
clinically, he applied to the regiment and received in return 
court-martial papers. The man confessed that he had made 
false statements and fled because he was afraid of shells. 
Reproached with simulation, he preserved a shameful silence. 



A fair exchange no robbery : France gets a simu- 
lator in an exchange with Germany of prisoners 
" unfit for service." 



Case 470. (Marie, April, 1915.) 

A French soldier arrived in France from Germany in a 
reciprocal exchange of prisoners supposed to be incapablefof 
bearing arms. The man showed a paraplegia with clonic 
movements of exaggerated degree. He was rapidly " cured " 
after being placed in a military hospital, and disciplined. 
He proved to be a vulgar simulator. 

It was clear that the German physicians had made a gross 
error in diagnosis; but what, asks Marie, should be done 
with such a man, since he evidently should not be given a 
convalescent leave or a retirement? Should he be sent back 
to his depot? 

If a year's treatment yields no results, Grasset suggests 
discharge with suitable gratuity. 



THE DIAGNOSIS OF SHELL-SHOCK 665 



SIMULATION : Question of Quincke's disease. 



Case 471. (Lewitus, May, 1915.) 

An infantryman was brought to the eye department of 
the Wieden Hospital early in May, 191 5, with a diagnosis 
(from the internists) of Quincke's disease. 

Under the conjunctiva of each globus oculi were count- 
less small air vesicles. There was not the slightest em- 
physema of the eyelids or of the skin about the eyes. The 
skin in the neighborhood of the zygoma was thick, red and 
swollen ; but no air could be demonstrated in the subcutane- 
ous tissues on palpation. Next day the skin swelling and 
the conjunctival emphysema had disappeared. No com- 
munication of the orbits with the air spaces of the skull 
could be demonstrated nor was it possible to push air into 
the conjunctiva by nose-blowing. The fundi were both 
normal and vision was normal. Special rhinological examina- 
tion showed the nose to be normal. It was the skin swelling 
of the orbital region that had given rise to the diagnosis of 
Quincke's disease. The man had been then referred to the 
internists who could, however, find no evidence of disease 
whatever. 

During the three months' stay of the patient in the eye 
department, once more swelling of the left orbital region 
and air under the conjunctiva of the left globus oculi suddenly 
appeared one day, but disappeared over night. At this time 
small subconjunctival ecchymoses were found. 

This case must be regarded as one of simulation but pro- 
duced in a manner unknown. 



666 THE DIAGNOSIS OF SHELL-SHOCK 



Bruises of head and back, not severe: "A case 
of pensionitis, a self-made neurasthenic for medi- 
colegal purposes." 



Case 472. (Collie, May, 1915O 

Sir John Collie remarks that sometimes one has to recom- 
mend a pension knowing that what amounts to a fraud is 
being perpetrated. A seaman, 25, got newspaper notoriety 
after receiving [some not very serious bruises of head and 
back. Two months later, when seen by Sir John Collie, 
he was a victim of bent back. He was finally able to remove 
his clothes and put them on with some alacrity, although at 
first he declared he could not. Woebegone during exami- 
nation, he was noted to laugh and gossip with strangers out- 
side. A physician had diagnosticated it as an obscure spinal 
lesion, but as he was fit to work, he was sent back. 

Forty-one days later he put himself on the sick-list again. 
Pluck and nerve were gone beyond recall, according to his 
physician. In hospital his appetite was good, he slept well, 
and he had no troubles except an hysterical loss of sensation. 
There followed 33 days in hospital, three weeks in a convales- 
cent home, and return to work for a month. Unable to 
stoop or kneel for pain, he was thought organic. 

Sir John found him without desire to get well, hysterical, 
and suffering " from pensionitis, a self-made neurasthenic for 
medico-legal purposes." He was placed for four months in a 
nerve hospital. On leaving this hospital he was still in the 
bent-back position, and went into a pantomime display when 
asked to touch his toes. Four weeks in the convalescent 
home found the following: The attending physician now 
suggested locomotor ataxia as the correct diagnosis! Sir 
John Collie was asked to report finally as to the fitness for 
work. Well assured that the patient was really a malingerer, 
Sir John nevertheless certified him as permanently unfit for 
further service as a case of traumatic neurasthenia, venturing 
to predict that after receiving the pension, he would be at 
work within six months. He received the pension (25 s. a 



THE DIAGNOSIS OF SHELL-SHOCK 667 

week for life), and Sir John Collie's ability at prediction was 
justified by his return to work, at the end of exactly six months. 
Re malingerers, Glueck remarks that a malingerer, besides 
being a malingerer, is a worthless sort of person in any 
event, and calls attention to the fact that special stresses 
may reduce men to lower cultural levels, to which lying and 
deceit may be more appropriate. Glueck remarks that the 
lay mind does not readily appreciate that a man with mental 
disease may at the same time be a malingerer of additional 
mental symptoms. It may be added that the professional 
mind is sometimes equally slow to appreciate the fact. 



668 THE DIAGNOSIS OF SHELL-SHOCK 



SHELL-SHOCK 

GROUP I. EXHAUSTION 

(Alcoholism perturbs treatment) 

GROUP II. HEREDITY 

(Certain poor recruits) 

GROUP III. MARTIAL MISFITS 

(Wrong attitude of mind) 

After Farquhar Buzzard 



Chart 14 



THE DIAGNOSIS OF SHELL-SHOCK 669 



NEUROSES AND PSYCHOSES OF WAR 

1. NEUROSES 

Motor 
Sensory 

2. NEUROSES 

Special Sensory 
Speech 

3. NEURASTHENIA 

Hemichorea 
Exophthalmic Goitre 
Trench Spine 

4. PSYCHOSES 

Minor 
Gun-shy, Insomnia, Dreams, Phobias, Psychasthenia, 
Hypochondria 
Stupor, Anergia, Acute Dementia 
Psychoses (Civilian Forms) 

After A. W. Campbell 



Chart 15 



" E pero leva su, vinci l'ambascia 

con l'animo che vince ogni battaglia 
se col suo grave corpo non s'accascia. 

"Phi lunga scala convien che si saglia: 
non basta da costoro esser partito 
se tu m'intendi, or fa si che ti vaglia. " 

"And therefore rise! conquer thy panting 
with the soul, that conquers every battle, 
if with its heavy body it sinks not down. 

"A longer ladder must be climbed: 
to have quitted these is not enough; 
if thou understandest me, now act so that it 
may profit thee. " 

Inferno, Canto xxiv, 52-57. 



670 



D. TREATMENT AND RESULTS OF 
SHELL-SHOCK. 

In previous sections we have already become acquainted 
with many therapeutic successes and failures : indeed it was 
almost necessary to detail treatment in certain cases to show 
the nature of the disease in hand or the correctness of a given 
diagnosis. In the present Section we approach the question 
more systematically. 

After presenting a few examples of various spontaneous and 
non-medical recoveries, we bring into contrast the types of 
medical recovery that may be termed rapid (or miracle) 
cures and those that fall under the general head of reedu- 
cation. Admixed are cases of failure as well as of success: 
if it be remarked that the case method puts forward the 
best foot, it is probable that the same is true of almost any 
therapeutics as reported in early articles. As we go to press, 
trench reports indicate that at least one part of the profes- 
sion is far more hopeful of successful psychotherapy even in 
the physiopathic group of disorders than their expounder, 
Babinski, could concede. The true statistical evaluation of 
the results must come years later. 

Some neuropsychiatrists have been fond of saying that 
there is nothing new in Shell-shock, that specialists have long 
been familiar with the psychoneuroses, etc. Yet in the 
past, specialists have not learned overmuch about the true 
inwardness of the psychoneuroses. Even a casual inspection 
of the various therapeutic efforts here described shows how 
much novelty of observation and ingenuity of plan must 
eternally be shown in these ever-so-simple psychoneuroses! 



671 



672 TREATMENT AND RESULTS 



Shell-shock : Deaf mutism. Spontaneous cure. 



Case 473. (Mott, January, 1916.) 

A British soldier, 25, a coal miner, had had a bicycle 
accident five years before, after which he was unconscious for 
2\ hours, and gave up work for five weeks, with headaches, 
fainting-fits, and nervousness ever after and with a tend- 
ency to imagine he could see things when there was nothing 
to be seen. 

September 19, 191 5, he was under shell fire in trench and 
dugout. A sergeant and three men working with him were 
killed by an explosion, and he remembers his cap being lifted 
off his head. He came to in 46 Rest Camp, some time later, 
unable to see clearly, or to hear or speak, and with headache 
and insomnia. He brought a paper from a hospital in 
France, saying, " Doctor, I had an awful dream last night 
again ; I was dreaming that I was in the trenches ; I could see 
the men falling and the great big shells exploding. I could 
see the light from the bursting of the shells very plain. They 
fairly lighted all the place up. I woke up very anxious I can 
tell you. I wish I could give over dreaming, and I keep 
having pains in my head right across my eyes." 

October 15, while sitting by himself outdoors, he felt a 
slight crackling in his head, noticed that he could hear sounds 
faintly, and in a few minutes he could hear fairly well. 

October 17, he was heard making inarticulate noises in his 
sleep. The corporal next him told him about the noises in 
his half drowsy state; he tried to speak and said, " Mother." 
He then felt queer all over, with pain in his head, and after- 
ward became able to talk very well with slight hesitation. 

Re spontaneous cures, Elliot Smith and Pear cite the 
cure of two mutes on hearing that Roumania had entered 
the war, and the cure of another by seeing Charlie Chaplin's 
antics. Some workers (for example, Aime), treat the func- 
tional mutes by simply leaving them to themselves, and 
maintain that they secure numerous spontaneous recoveries, 
regarding these as superior to cures by isolation, psycho- 
therapeutic treatment^and the like. 



TREATMENT AND RESULTS 673 



METHODS OF PSYCHOTHERAPY 



HYPNOSIS 
Verbal Suggestion 
Fixation 
Fascination 
Various 

SUGGESTION (WAKING) 
Verbal 
Drug 
Apparatus 

AUTOSUGGESTION 

DISTRACTION 

TERRORISM 

INFLICTION OF PAIN 

PERSUASION 

WILL TRAINING 

OCCUPATION THERAPY 

ISOLATION 

PSYCHOANALYSIS 



Chart 16 



674 THE DIAGNOSIS OF SHELL-SHOCK 

Re mutism spontaneously or non-medically cured, see also 
cases 476, 480, 481, 482. For various medical methods of 
treatment, see, e.g., cases 516, 518, 520, 526, 544, 579. 

Mott had a case which had been mute more than six 
months, unable to whistle, phonate in coughing, or blow 
out a candle, though heard to shout in his sleep: This 
patient recovered his speech when pitched out of a punt on 
New Year's Eve. The condition was in one sense physical 
enough, as the X-ray showed that the man's diaphragm 
hardly moved even with the greatest effort. Mott regarded 
the inhibition of the breathing movements, especially the 
phonation, as caused by fear. Mott speaks of a case that 
recovered on being told by a comrade that he had talked in 
his sleep. The man was so astonished by this statement 
that he said, "I don't believe it." Other instances of cure 
under quasi natural conditions are related by Mott: In the 
presence of a functional mute, Mott speaks loudly to the 
patient's sister so that the patient may hear: "This man 
must be kept on a No. 1 diet, and when he can ask loud 
enough for you to hear, he can have a bottle of stout and a 
mutton-chop." Several mutes are reported to have gotten 
well the next day under this treatment. 

These effects shade imperceptibly over into the mani- 
festly suggestive, and probably no sharp line can be drawn 
between the effects of medical suggestion, non-medical hetero- 
suggestion, and even autosuggestion. Adrian and Yealland 
rather decry the Micawber line of waiting for something to 
turn up. Zeehandelaar, a Dutch professor, studied Berlin 
methods (Lewandowsky) , and found numerous cases (both 
of mutism and of deafness, paralyses, contractures, and 
tremors) lying about without special treatment. According 
to this observer, the expectant treatment was sometimes 
successful, and sometimes not; if unsuccessful, the soldier 
was sent home, and re-examined a year later; whereupon 
he might be found to have profited by this long waiting and 
to have gotten well enough to return to army duty. 



TREATMENT AND RESULTS 675 



A decorated officer, evacuated for Shell-shock on 
the third day of the Aisne, after four days returns to 
the front. Evacuated a second time, after weeks 
returns to the front without relapse. 



Case 474. (Gilles, 1916.) 

A young officer, with many decorations for brilliant Colo- 
nial service, was in the battle of the Marne, under six con- 
secutive days' shell fire, smoked phlegmatically a cigarette 
no matter whether walls were crashing or horses disembow- 
eled beside him, and was uniformly able to stimulate his 
men to the heavy work by humor or heroic phrases. 

A week later, on the third day of the Aisne, he had to be 
evacuated. He was another man — wild-eyed, shivering, 
jumping at the least noise, unable to eat or sleep, given to 
battle dreams. He had to be carried away from the battle 
zone and put in a bed in a town in the rear and given chloral. 
The nightmares continued. On being awakened he would 
ask where he was. He was kept in bed, given strychnine 
cacodylate, and dieted. He went back to the front in four 
days. Two days later he had to be evacuated a second time. 
After some weeks more in the rear, however, he went back to 
the front, and thereafter had not relapsed (April, 1916.) 

Re relapses, Wiltshire thinks their causes and frequency 
prove the psychogenic nature of Shell-shock. Ballard states 
that a severe case lasting six months does not recover in the 
army. Many that are said to recover in hospital break down 
at depots, often with symptoms quite unlike those which they 
originally presented, and it will be remembered that Ballard 
has an epileptic theory of the nature of Shell-shock. See 
Cases 82, 83, and 84 in Section A, III, Epileptoses. But 
another portion of Ballard's contentions relates to a causa- 
tion through fear suppressions released by perturbing events. 
According to Ballard, if the man endeavors to re-suppress 
the released fear, the fits occur. Ballet and DeFursac note 
the frequency of relapses — fewer after treatment at the 
front. 



676 TREATMENT AND RESULTS 



Vicissitudes in fifteen months of a Shell-shock case 
with mutism and amnesia. Attacks of mania. 
Hyperthyroidism? 



Case 475. (Purser, October, 191 7.) 

An Englishman, 21, in a rifle regiment, arrived in May, 
19 1 5, at the Dublin University V. A. D. Hospital, being 
dumb, impaired as to vision and hearing, having dilated 
pupils, tremors, restlessness and weakness, and giving the 
impression of visual hallucinations. Although suspicious, 
he was treated kindly for a few days, recovered his hearing, 
and wrote the few things that he remembered about home 
and the war, now and then tremulously and perspiringly 
writing down, " Asylum; do not lock up; I am not mad." 

With the idea of hypnosis, his bed was surrounded by 
screens, whereupon he grew so perturbed that the attempted 
hypnosis could not be executed. He learned the letters 
PP, TT, SSS, A-OOO, and finally AA-SS, AA-TT, T-OO, 
and after many weeks SS-SST-R and B-TT-R. His father 
visited him and probably was recognized. 

At the end of September another dumb Shell-shock case 
recovered speech upon being given ether. Maj. Purser asked 
the sister to arrange for a like treatment for the first case, 
explaining that an examination of his throat might be pain- 
ful. The cure of the second case by anesthesia got into the 
papers and before he was treated the account was possibly 
seen by the hitherto gentle rifleman. At any rate, he was 
seized with a sort of spasm, became furious and could only 
see Germans coming and carrying off his machine gun. He 
shouted for help. A half grain of morphine was given him 
and when it began to take effect the fighting spirit gave way 
to despair. He trembled over the loss of the gun, and re- 
mained in this state of despair for three days, remembering 
his regiment number and the like, but amnestic for his life 
during the past few months. He could not read now be- 
cause print was indistinct. Words, when he had spelled 
them out, conveyed no meaning. He had a functional alexia. 



TREATMENT AND RESULTS 677 

When he saw a picture of a bunch of flowers in a notebook of 
his, he had another spell of excitement and regained his power 
of speech, remembering about his experiences only that he 
had been locked up. He had now completely forgotten his 
father, who came to call. 

By the end of October he was stronger, but his horizon was 
still limited to the hospital surroundings and a little news- 
paper reading. Headaches and impaired vision persisted. 
Sight temporarily left him early in November, and there was 
a suggestion of an epileptic fit one day early in that month. 
Tonic and sedative drugs and suggestive remedies were of 
no avail. Hypnotism made him worse, and psychanalysis 
was, perforce, ineffective through the amnesia. At the end 
of November depression and suicidal thoughts set in, with 
an elevation of blood pressure to 178 m.m., pulse 80 to 90. 
Maj. Dawson then thought he was a suicidal melancholic. 
Rest in bed and thyroid extract were given, but the latter 
threw up his pulse on the fifth day to 140. He grew better 
mentally on the treatment, however, and his blood pressure 
fell to 140 in three weeks. He was now over- emotional, 
unable to stand or walk or feed himself or to pull on his socks. 

For change of scene he was transferred to Mercer's Hos- 
pital in February, 1916. He suffered from astasia- abasia. 
The tremor became jerky, coarse and persistent. The thy- 
roid gland grew a good deal in size during the spring and the 
pulse went up to 120 per minute. There was also well-marked 
dermographia and there was a suggestion of the clinical 
picture of Graves' disease. Even a quarter grain of morphine 
had little or no effect upon an ineradicable insomnia. 

Maj. Purser gave the case up as a bad job and the man was 
discharged and sent home September 2, 1916. During the 
next two months at home he improved in steadiness, though 
he flushed if dealing with strangers, and improved as to mem- 
ory. He began to be able to read better. He had begun to 
be able to get about on his feet without so much support. 
The ultimate outcome could not be reported by Maj. Purser. 



678 TREATMENT AND RESULTS 



Shell-shock : Mutism. Cure after killing a snake. 



Case 476. (Jones, 1915.) 

An Australian soldier of 20 went to Egypt, thence to Gal- 
lipoli where, on July 29, 191 5, he was almost completely buried 
by earth from the bursting of a high explosive shell. He 
was admitted to hospital August 5 and transferred to Malta, 
where he did not speak, stared into space and sometimes 
made, impulsively, attempts to get away. About September 
17 he began to assist the orderlies and played draughts. 

The diagnosis there was cerebral concussion. He was sent 
back to Australia by transport and had to be put in a padded 
cell on November 1 , having become violent, noisyrand destruc- 
tive. He would assault anyone who beat him at the game of 
draughts and threw anything he could lay his hands on out 
of the porthole. Hyoscine he resented and threatened the 
givers by signs. He was at times restrained. He threat- 
ened to throw himself overboard. Diagnosis: Melancholia. 

At Melbourne he was found in good physical shape, but 
dazed, mute, apparently deaf, indicating his wants by signs. 
With pencil and paper he would draw a ship or a gun and 
would copy any question put to him in writing. He played 
draughts intelligently and made friends with one of his ship- 
mates. In four days' time he began to communicate in writ- 
ing, answering simple questions correctly. Asked to put a 
question, he wrote " Do you think I am mad?" On the ap- 
propriate answer he shook hands with the physician heartily. 

He was then sent to a military convalescent home at 
Highton. Here he communicated often in writing, and had 
an appreciation of sounds without distinguishing words. 
At a picnic on December 4 he killed a snake. While return- 
ing in the dark he began to whistle a song the rest of the 
party were singing. At the end of the song he clapped his 
hands and said, " What is the next item on the program ?" 
Thereafter he was able to hear and speak. Seen four days 
later he asked to join the officers' training school. However, 
he was discharged as permanently unfit for the service. 



TREATMENT AND RESULTS 679 



Course in hospital of an oniric delirium. 



Case 477. (Buscaino and Coppola, January, 191 6.) 
An Italian gun-maker, 27 (father neurotic; grandmother 
and mother, alcoholic; patient excessive onanist), was called 
to arms June 14, 191 5, and went into artillery service in the 
Tolmino, early in September. Some time later, a shell burst 
about 30 meters away and killed his lieutenant. The pa- 
tient, however, was not hurt and did not even fall. He be- 
came mute and inaccessible, and was sent to a military 
hospital, and thence to an asylum in Udine, where he was 
restless and hallucinatory. October 2, he was sent to Flor- 
ence on two months' leave for convalescence. He was still 
hallucinated, always seeing his dead lieutenant. He spoke 
rarely, slept little, and his conduct became more and more 
queer. Now and again, he would act exactly as if he were at 
the front. November 5, he started off to find his brother, 
but was met by a hospital attendant, who promptly took 
him to a clinic. Here he was inaccessible and lived in a 
hallucinatory way a soldier's life at the front: in continual 
movement, shielding his eyes with his hands as if looking far 
into the distance, bending down to turn an imaginary lever, 
apparently taking part of his aim, crouching in a corner, 
clapping his ears with his palms, and obeying hallucinatory 
commands: " Ready," "Fire," and the like. As to his in- 
terpretation of the actual surroundings, he would give a 
military salute at the entrance of the physician, as if he were 
the lieutenant. Another patient near by was interpreted as 
a spy. Hypodermic injections, November 6, were inter- 
preted as military antityphoid injections. On succeeding 
days he piled dry horse-chestnut leaves for a parapet, which 
became the scene of battle. November 12 he had become a 
little more lucid. November 14, he evidently heard whist- 
ling and made the leaves ready as a bed for horses. Novem- 
ber 15, he rolled up his blanket in a military fashion and hid 
in a cell corner. He explained, November 16, that he was a 
sentinel and had not been relieved by the corporal. He had 
saved everybody's lives by signaling from a tree the presence 



680 TREATMENT AND RESULTS 

of four airplanes. He could not be convinced he was in an 
institution for the insane. November 20, he was virtually 
recovered but amnestic for what he had done since commit- 
ment. Headaches and dizziness. November 21, he remem- 
bered some of his dreams, especially one of being blinded 
and another of being tied by a German to a tree. By No- 
vember 29 he had become lucid and oriented, but there was 
an amnestic gap for his stay at the clinic. Early in December 
the fields of vision were contracted; polyopia and a glaring 
and burning sensation before the eyes (after each test con- 
junctival and tear duct inflammation). 

December 21, discharged well. 

Re the nature of oniric delirium, see discussion under 
Cases 333 and 450, Chavigny had but two cases out of 260 
in which a rapid curability was noted (90 per cent finally 
curable). Chavigny's treatment consists of rest in bed, 
quiet, purgation if necessary, and warm or cold shower 
baths. Chavigny remarks upon the extraordinary trans- 
formation from apathy to lucidity in the course of a few 
minutes, brought about by arranging a slight but definite 
emotional shock to the patient, namely, by mentioning in his 
presence something about home or family. One bit of tech- 
nic was to get the patient to write or dictate a letter home. 

Regis remarks that battle dreams of this nature occasion- 
ally affect alcoholics in garrison or at home. The victim 
ought not to be hastily committed to an asylum, but should 
be treated in a military neuropsychiatric service with isola- 
tion chambers and open wards. Regis organized early in 
the war at Bordeaux a central psychiatric service along these 
modern lines. He remarks that the central service ought 
to receive not only patients from the military hospitals, but 
also patients from the temporary auxiliary hospitals of the 
city and district round about. A pooling of the military 
and civilian issue upon rational lines is here indicated. 

Regis and others have remarked upon the necessity of 
differentiating these battle deliria from toxic and infectious 
psychoses. 



TREATMENT AND RESULTS 68 1 



Shell explosion: Deaf mutism, recovery of speech 
with electrical treatment; deafness cured by sug- 
gestion in writing. 






Case 478. (Buscaino and Coppola, January, 1916.) 
A fusileer, 20 (mother neurotic, brother hemiparetic from 
infantile disease ; patient had extreme otorrhea from an early 
otitis media), entered the army January 15, 191 5. He was 
sent to the Isonzo in May and was slightly injured in the 
nape of the neck and the left calf by fragments of a shell 
that exploded near by. He was picked up unconscious and 
taken to the hospital at Servignano. There he was given 
electric treatment, and in a period of 18 days recovered his 
speech, passing through a phase of stammering. He was 
sent to a special hospital in Florence, still deaf, and passed 
into a state of mental excitement with visual hallucinations 
of soldiers. He was given chloral and bromide. He in- 
sisted that he was incurably deaf. August 22, he was ad- 
mitted to Buscaino's clinic, completely deaf, slightly stu- 
porous, somewhat indifferent, and innocent of any effort to 
make himself understood (contrary to the habits of an or- 
ganically deaf person). Simulation could be excluded. It 
was possible to awaken the patient during sleep by auditory 
stimuli, whereupon he opened his eyes but could not hear. 
He talked well and spontaneously, telling about his accident, 
reading and answering by signs. He was assured, — always 
in writing, — that upon the following Sunday his hearing 
would be restored. Upon that day, during the visit of a 
lady, — one of the patient's friends, — hearing was suddenly 
and almost completely restored in the left ear. The patient 
was so moved by this that he cried when the physician came. 
Upon the following day, he gradually began to hear with his 
right ear. A slight diminution of hearing in the right ear 
persisted, however, until September 24, and was associated 
with headache and pains in the left ear — pains which the 
patient compared to his ear pains in childhood (remains of 
otitis with retraction of the tympanic membrane). 



682 TREATMENT AND RESULTS 



Paraplegia : Cured by administration of Iron Cross. 



Case 479. (Nonne, December, 1915.) 

After heavy shelling a soldier fell for two days into a 
clouded state from which he waked with complete paraplegia 
of the lower extremities, and total anesthesia from the pelvis 
downward (reflexes and electric excitability normal). 

On the third day after his reception in Nonne's wards, 
he was about to be hypnotized when news came that he had 
been promoted to a lieutenantcy and had received the Iron 
Cross. He fell forthwith into hysterical convulsions, in the 
midst of which the hitherto paralyzed legs worked perfectly 
well! Even after the hysterical attack was over, the man 
could still move his legs in bed normally, but had absolute 
astasia- abasia. Next day, with deep hypnosis, markedly im- 
proved. After eight more days of hypnosis the new lieuten- 
ant got back his normal gait. 



Shell-shock, burial : Mutism. Cure by getting drunk. 



Case 480. (Proctor, October, 191 5.) 

A patient, 25, nine years in the service, was buried in a 
dugout by an explosive shell at Ypres, June 17, was taken 
out unconscious, and eventually reached the hospital at 
Versailles. Consciousness had returned a few days after the 
injury. There was ringing in the ears, difficulty in hearing, 
and inability to speak. He arrived at the Duchess of Con- 
naught's Hospital at Taplow, July 12, when, aside from the 
above-mentioned symptoms and a rapid heart action (108 at 
rest), he seemed perfectly well. About August 14, he began 
occasionally to refuse solid nourishment and remained in bed, 
eyelids closed but twitching at times, especially when spoken 
to. He resisted having his eyelids opened. 

August 27, he was allowed to go to the village with 
companions, and got drunk, found his voice, for two days 
talked and sang incessantly. Discharged September 9, cured. 



TREATMENT AND RESULTS 683 



Shell-shock and burial : Mutism. Cure by work in 
a vineyard with wine to drink. 



Case 481. (Anon, May, 1916.) 

A correspondent of the British Medical Journal reports a 
case of cure of emotional mutism. This robust young 
soldier at Verdun was buried by the explosion of a shell and 
was thereafter found unable to speak. A week later he 
arrived at the ambulance in the interior, and was still mute. 
He could understand what was said to him without difficulty, 
and was able to reply by signs. He did not even move the 
lips when requested to pronounce such words as mamma and 
papa , but was eventually induced to whisper these words. 

The laryngoscope showed complete paralysis of the vocal 
cords, which were in extreme abduction (it was possible to 
see several tracheal rings). There was no reaction on the 
part of the pharyngeal mucosa upon stimulation. 

A fortnight passed without restoration of speech, though at 
one time, not having bolted the closet door, the patient was 
startled when a nurse rushed in, and he said, "Oh, pardon, 
Madam." The mutism persisted. He was then given work 
in the vineyard, plenty of wine to drink, and hard work. 
After a time (not specified) speech suddenly returned. Ac- 
cording to this correspondent, " this indeed is a universal 
experience, namely, that hard manual work is the best 
remedy for such functional incapacities of traumatic origin." 

Re Cases 480 and 481, compare cures by anesthesia with 
chloroform, nitrous oxid, and the like. 

Re gradual cures as opposed to sudden ones, Dundas 
Grant deprecates violent measures in the treatment of 
mutism during the period of exhaustion after Shell-shock. 
However, Dundas Grant does not advocate an expectant 
treatment, but employs a gradual reeducation of the voice 
through imitation of the teacher. The voice is sometimes 
restored at a sitting, sometimes gradually; see, for example, 
Case 578 of Briand and Philippe, and Case 586 of MacCurdy. 



684 TREATMENT AND RESULTS 



Shell-shock, unconsciousness : Deaf mutism : Spon- 
taneous recovery of speech and gradual recovery 
(several months' isolation) of hearing. 



Case 482. (Zanger, July, 1915.) 

A musketeer was deafened and stunned by a near-by 
shell explosion. On coming to, he found no wound, but was 
deaf and dumb. 

Speech returned after ten days, and hearing partially, but 
there was a tonic stuttering. He had to hunt anxiously for 
words, talked like a child in infinitives and telegram style, 
although he could express himself in writing perfectly well. 

Hearing improved on the right side very quickly, but on 
the left side conditions varied from total deafness to subtotal 
deafness. There was a general hyperesthesia of the skin, 
pain on pressure on the temples, exaggeration of skin and 
tendon reflexes, marked tremor in both hands. The man 
was anxious, depressed, and irritable. During caloric tests 
of the vestibular apparatus in the course of the next few 
weeks, the man had an hysterical attack of crying twice, 
following which all the phenomena got worse. 

Rest and isolation from all such influences procured an 
almost complete recovery in several months. 

Re differential recoveries, see also Case 585 of Liebault, in 
which speech was recovered by suggestion and reeducation, 
and hearing by a process of reeducation alone. 

Re isolation, Roussy and Lhermitte remark that in all the 
psychoneuroses of war, isolation is a valuable and indeed 
an indispensable aid to psychotherapy. The application of 
this old classical method of Weir Mitchell reinforces the 
persuasive talk of the doctor on the day of admission, allows 
the man to think over the promises made to the doctor, and 
permits longer observation. It depends on the case, whether 
rigorous isolation on limited diet shall be employed. See 
below a general discussion of the psycho-electric and re- 
educative method employed in French centres. 



TREATMENT AND RESULTS 685 



Marches ; battles ; slight shell wound of left upper 
arm : Hysterical anesthesia of the arm and tremors 
(NO paresis). Causes slight — disease obstinate 
(partly explained by furloughs among sympathetic 
friends). 






Case 483. (Binswanger, July, 1915.) 

A soldier, 26, without heredity, always well, in long 
marches and several battles early in the war, August 23 
sustained slight shell wounds of thighs and left upper arm. 
He was unconscious about five minutes. In eight days, the 
wounds were healed, and all movements were free. 

Immediately after the trauma the arms trembled, and at 
times the legs. Treatment was instituted (baths, drugs, 
massage, electricity), but without result. After a month's 
treatment and a furlough at home, the patient was sent, 
January 3, 191 5, to the Jena Nerve Hospital. He was a 
powerful man of middle size, with some small movable scars 
on the left upper arm, remains of the shell injury; two 
similar scars of the gluteus maximus. The deep reflexes 
wereslightly exaggerated, as were the skin reflexes. The 
touch and pain sense in the left arm was absent as far as the 
shoulder in typical segmental fashion. Arm movements 
were free; there was an occasional tremor in both arms, 
especially the left. This tremor would pronouncedly in- 
crease upon intentional movements and with emotion. 

He said that about two weeks before, at home, he had 
waked up in the night and lain down on the floor beside 
his bed, feeling giddy in his head. In a week the tremors 
had diminished, leaving only a very slight tremor of the left 
hand. The patient went to considerable pains to conceal 
his tremor, holding his hand in a military position at the 
seam of the trousers, on the medical visit. Sometimes he 
would succeed in making the tremor quite disappear. Feb- 
ruary 5, he was busy about the ward work, going errands 
and carrying trays. He would intentionally spare his left 
hand in this work. Upon trying gymnastic exercises, the 






686 TREATMENT AND RESULTS 

tremors of the left hand and also of the right reappeared. 
After a few days these tremors again disappeared, only to 
come back on the 12th, when there was a constant tremor 
also when the patient was at rest. He had been affected 
when observing another patient (8*). Accordingly, he was 
separated from this patient and put in a psychiatric ward. 
The tremor remained of varying intensity, sometimes being 
absent for hours together. 

Request for furlough at the beginning of March was re- 
fused with the statement that it would be granted when cure 
was complete. The patient was inaccessible to psychothera- 
peutic influence. He was always of a friendly, modest de- 
meanor, sleeping well, and performing all bodily functions 
properly. On any exertion the pulse ran to 134. The 
heart was normal. There were outbreaks of perspiration. 

March 26, he renewed his request for leave, desiring his 
Easter furlough. He was told he might expect it. March 
31, the tremor was found to have quite disappeared. Upon 
his return, April 12, there was a marked tremor of the left 
arm, especially of the wrist joint, which again disappeared 
after some days. The middle of June he was released as 
capable of garrison duty with the recruits. 

If there was a mechanical factor in this case, it must have 
been the shaking-up of the body by the shell explosion. His 
skin lesions were slight. The main factor was doubtless the 
emotional shock. The tremor supervened upon a very brief 
period of unconsciousness. It is hard, according to Bins- 
wanger, to explain the localization of the cutaneous anes- 
thesia without the development of a corresponding paresis. 
May it be, inquires Binswanger, that the wound of the left 
upper arm at the moment of the setting-in of unconscious- 
ness, or perhaps at the moment of waking from unconscious- 
ness, directed the mind forthwith upon the left arm and in 
this way produced localized disorder of sensation? If so, 
why did the wound of the gluteal region not produce cor- 
responding disorders of feeling and sensation of an hysterical 
nature? The obstinacy of the disease stands in striking dis- 

* See Case 8 of Binswanger's article. 



TREATMENT AND RESULTS 687 

proportion to the slightness of the causative factors at 
work. 

According to Binswanger, this is perhaps due to the long 
furlough which the patient had. According to Binswanger's 
experience, as that of many others, home works badly for 
these hysterical patients ; their friends sympathize with them 
too much. 

Re furloughs, Ballard states that severe Shell-shock cases 
should get analogous treatment to that of civilian psychoneu- 
rotics, namely, a complete removal from the environment 
in which the illness began. He advocates three months' 
leave, after which the man is to be sent to a convalescent 
home, and thence to a command depot. He states that if a 
relapse then occurs, such a patient will never be a soldier. 
Ballard would allow the men to walk about with their "pals 
(not with escorts)." Cimbal remarks that German data 
show that home furloughs should be avoided in every in- 
stance where possible. Fiessinger remarks, on the basis of 
English experience, that a Shell-shock patient treated by 
rest, suggestion, and manual occupation may go back to the 
line "and on a subsequent occasion prove a hero." (See 
Case 474 of Gilles.) But Forsyth remarks that it is prob- 
ably injudicious to send any cases of Shell-shock, with few 
exceptions, back to the firing line, because their fighting 
value has been permanently deteriorated, and because, if the 
fear of return to the trenches is removed, recovery is more 
rapid. The experience here is not unlike that of industrial 
accident board cases with rapid recovery after the decree of 
compensation. 



688 TREATMENT AND RESULTS 



War stress in a volunteer banker: Hysterical 
seizures. Treatment by hydrotherapy. 



Case 484. (Hirschfeld, February, 1915.) 

A banker, a volunteer (articular rheumatism at three 
years; at 18, some form of lung and tracheal inflammation; 
tendency to fainting spells on cold days — heart disease was 
said to have been found), as a result of the strain and excite- 
ment of the war had hysterical attacks during a fortnight 
before observation in hospital, consisting of sensations sud- 
denly developing in the region of the heart, stiffness of the 
whole body, disorders of movement, without loss of con- 
sciousness. 

November 23, 19 14, he was examined in bed in the dorsal 
position, with the muscles of the legs, back, and neck in a 
state of tonic contraction. He was unable to answer ques- 
tions. The pupil reactions were normal in the seizure. The 
attack ceased in two minutes, as the result of hitting heavy 
blows on the chest with a moist handkerchief and the threat 
of a strong and painful application of the electric current. 
The patient then got out of bed at request, walked about a 
little incoordinately for a time, but after a few minutes was 
able to walk perfectly and to talk once more. 

Examined, November 25, he was found to be pale, fairly 
well nourished, with a somewhat accelerated pulse, and a 
melancholy, slightly apathetic expression. A systolic mur- 
mur at the right apex; accentuation of secondary pulmon- 
ary sound; increased knee-jerks; trembling of the lids 
(Rosenbach). 

By December 12, the patient was completely well. The 
seizures had not recurred. The treatment was by hydro- 
therapy. A preliminary treatment is advocated by Hirsch- 
feld, to insure peripheral circulation, either by light 
baths, hot douches, or packs. More important than this 
preliminary treatment is the cooling off process by means of 
tepid douches or partial baths. These partial baths are 
given at 2 8° C. for the intense effect of the cold. Some- 



TREATMENT AND RESULTS 689 

times this treatment can be concluded with a dry pack. The 
patients are treated by Hirschfeld three times a week with 
both the warming and the cooling procedure. 

Re hydrotherapy, Mott has found the continuous warm 
bath of great value in Shell-shock cases coming back from 
France. He keeps the patient in the water from a quarter 
to three-quarters of an hour, or longer. A warm bath and 
a drink of warm milk at bedtime may permit a man to get 
on without hypnotics, or to get on with lesser amounts of 
hypnotics. The effect of these baths is doubtless largely 
somatic. Some writers stress the suggestive value of hydro- 
therapy as well as of electricity, radiant heat baths, and the 
like (Ballard). A neuropsychiatry center properly equipped 
with a hydrotherapeutic plant can do therapeutic work by 
means of the suggestion afforded by a cold shower, which 
may act quasi miraculously, like electricity (Roussy and 
Boisseau). In fatigue and exhaustion cases, along with ad- 
renalin and strychnin, Aime gives mild hydrotherapy without 
other sedatives. Laehr's free sanatorium at Schonow treats 
the arythmia and tachycardia cases with rest and hydro- 
therapy. 

Brasch reports rather poor results with hydrotherapy in 
the cardiac neuroses. Weichardt has used the continuous 
bath as a form of psychotherapy and permits the symp- 
toms of psychoneurosis to subside therein. 



69O TREATMENT AND RESULTS 



Shell-shock : low blood pressure : Pituitrin. 



Case 485. (Green, September, 191 7.) 

A lance corporal of the Expeditionary Force, 26, went to 
France feeling very fit, February, 191 6. He was blown up by 
a shell July 1, and faintly remembered crawling out of some 
water. He came to in a dugout, dumb and partially deaf, 
and was blind for a few minutes. August 17, he was ad- 
mitted to Mott's wards at Maudsley, mute but with hearing 
normal. The hands were dusky, sweating, cold, and slightly 
tremulous. He was given to battle dreams and used to 
wake in a sweat and terror after a pantomime of bomb- 
throwing. He had headache and was depressed. He com- 
plained of feeling cold and the surface temperature was 
subnormal. The blood pressure was also subnormal (accord- 
ing to Green, nightmares are most marked in cases with low 
blood pressure ; these are, in fact, severer cases of Shell-shock 
than cases with high blood pressure; only 10 of 27 cases with 
blood pressure above 120 showed nightmares). 

September 25, he was able to speak in a whisper. The 
dreams had become less terrifying. The other symptoms 
had been slowly improving. 

November 25-28, all of the symptoms returned upon hear- 
ing the death of his brother in action. 

The man was now put on extract of pituitrin gr. 2, t.d.s. 
(better results are claimed by Green from pituitrin extract 
than from pituitary fluid injections, as these sometimes cause 
dizziness, of which no case treated with extract complained). 
As in other cases, the extract was immediately followed by 
an increase in blood pressure, a general improvement and a 
diminution of headache and depression. The bomb-throw- 
ing pantomimes still persisted, but the patient was less weak 
on waking. The treatment was continued for seven days, 
whereupon the surface temperature began to rise and the 
patient himself felt that he was much warmer. The pitui- 
trin was discontinued after a month's treatment, yet the im- 
provement persisted. The man was boarded out of the army 
and in March, 191 7, wrote that he was still feeling better. 



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Blood pressure, surface temperature, and pulse in a case of functional mutism, fa) On admission, 

troubled by nightmare, (b) Able to speak in a whisper, (c) Much depressed after bad news. 

(d) Put on pituitrin. (e) Marked general improvement, (f) Taken off pituitrin. 




A — i Showing the effect of pituitrin on the blood pressure and surface temperature. Each dot is one 

week's interval. + is the pressure when the first dose was given. © is the 

point at which the pituitrin was discontinued. 



SHELL-SHOCK, PITUITRIN, AND BLOOD PRESSURE (EDITH GREEN) 



TREATMENT AND RESULTS 69 1 



Various treatments of a contracture of hand. 



Case 486. (Duvernay, November, 1915.) 

A chasseur, 22, received a bullet wound in the anatomical 
snuffbox, the bullet emerging under the styloid process of 
the radius, having traversed the back of the hand without 
striking bone. Healing was rapid, but the hand assumed a 
peculiar position. The second and third phalanges of the 
fingers were extended, whereas the first phalanx was flexed. 
The four fingers were as if glued together. Both phalanges 
of the thumb were flexed, the wrist was in extension, and 
the tendon of the palmaris seemed contractured. The 
fingers could not be moved and the wrist was very mobile. 
There was pain on attempts to move the hand passively, 
and small clonic contractions were made by the fingers. 
There were no sensory disorders, but there was a maceration 
of the interdigital spaces. 

Mechanotherapy accelerated the contracture, and mas- 
sage, motor reeducation, bromides, and sedative drugs, had 
no effect. Under kelene-anesthesia the contracture would 
disappear. In January, 191 5, the hand was put up in plas- 
ter in a position opposite to the contracture. The intense 
pain of the first days was treated by opium. The patient 
was sent on leave, and, at the end of two months, the plaster 
was removed; but] the hand at once resumed its faulty 
position, and attempts to alter its position again provoked 
pain. Elastic traction was then tried for six weeks, and the 
bad position was somewhat modified but not improved by 
hyperextending the second phalanx on the first, and putting 
the third in slight flexion on the second. Hot compresses 
were unsuccessful also. May 14, 191 5, the position was still 
irreducible; there was no R. D. or electrical hyperexcitabil- 
ity. This was not a question of radial paralysis, since finger 
extension was distinct; nor a paralysis of the median, since 
the thumb was flexed. The contracture, in fact, does not 
affect a special nerve territory, and the disorder is in the 
ulnar, radial, and median territories. 



692 TREATMENT AND RESULTS 



Orthopedic case. 






Case 487. (Sollier, November, 1916.) 

A patient suffered from a rupture of the peroneal nerve in 
its lower part, September, 191 5, and had operation scars 
before and behind the external malleolus. He was immo- 
bilized for 45 days at first, and then for 30 days, with the foot 
in extension on account of the pain produced in the endeavor 
to put it into normal position. A 6 cm. atrophy was then 
found to affect the calf, and there was a fibrous retraction 
of the tendo Achillis and of the calf muscles. There was 
no anesthesia, the toes moved easily, the foot was fixed in 
equinus, with about 7 cm. of the heel above the ground. He 
was placed in various orthopedic institutions and was treated 
with mechanotherapy, but without result. 

At the neurological center, however, in six weeks, he was got 
to walk, with his heel on the ground, by means of massage and 
manual mobilization. The atrophy diminished a centimeter 
and the foot became mobile in all directions. 

According to Sollier, mechanotherapy by means of appa- 
ratus is apt to be ineffective, especially in contractures, be- 
cause its action ceases the moment it ought to commence, 
namely, when the patient is beginning to react a little pain- 
fully after recovery from anesthesia. In cases of retraction, 
mechanotherapy with apparatus does not allow the proper 
combination of massage with progressive mobilization. 

Re orthopedic cases, Jones classes the conditions that 
create an orthopedic case under four heads (note espe- 
cially the fourth) : 

1. Mechanical injury to bone, joint, muscle, or nerve. 

2. Atrophy and disease of these structures primarily due 

to the injury. 

3. Incoordination of movement due to disease of the 

brain — a result of atrophy and disease of periph- 
eral structures. 

4. Psychological conditions which can be overcome by 

reeducational processes. 



ROTATION 

OF 
SHOULDER 



ANKLE 
EXTENSION 





■?*? 




ANKLE 

EXTENSION 



FLEXION 

AND 
EXTENSION 



ELBOW 

FLEXION 

AND 

EXTENSION 





ROTATION 
OF HIP 




CIRCUM- 
DUCTION 
OF THIGH 



MECHANOTHERAPY (COLOLIAN) 






TREATMENT AND RESULTS 693 



Favorable effects of lumbar puncture. 



Case 488. (Ravaut, August, 1915.) 

An accountant, 20, in the 135th infantry sustained shock 
from mine explosion near his trench, March 6. He was 
kept two days at the relief station. March 8, at the 
ambulance, he did not appear to understand questions and 
had a fixed stare. He complained of a violent headache and 
kept pressing his head between his hands. He kept looking 
about him anxiously, and the slightest noise made him jump. 
He would mutter a few incomprehensible words, and in reply 
to a question would give only the last phrase which he hap- 
pened to have been saying. Lumbar puncture showed a 
very slight excess of albumin. Next day, he answered his 
name. March 12, he could speak in monosyllables, and he 
began to understand what was said. After the lumbar 
puncture, the headache disappeared and did not set in again. 
March 13, he began to be able to write and say short phrases. 
March 16, expression was good though hesitant, and the 
patient wrote a letter to his parents, telling about his shock. 
Lumbar puncture showed that the albumin was now normal. 
From the rear, April 5, the patient sent Ravaut a postcard 
in perfect form, telling how he was ready to go back to the 
front. 

Re lumbar puncture, Imboden quotes Podmanizky as hav- 
ing used lumbar puncture as a method of suggestion for the 
cure of abasia. See also cases 560 and 561, in which Claude 
cured two cases of dysbasia by the device of stovaine anes- 
thesia of the spinal cord. Pastine also has a case in which 
a slight improvement was produced on removal of cerebro- 
spinal fluid, and a sudden and complete cure was brought 
about by the second puncture, a very painful tap. Pastine's 
case is thought by him (19 16) to be in part at least organic. 



694 TREATMENT AND RESULTS 



Bullet wound of forearm: Hysterical clenching 
of fist. Recovery by fatiguing the flexors. 



Case 489. (Reeve, September, 191 7.) 

A soldier, 28, was thrice wounded between August 18, 19 14, 
and July 14, 1916. The third time, a bullet passed through 
the fleshy part of the forearm, whereupon the hand became 
clenched and remained so after the wound was surgically 
healed. As a case of war neurosis, the man was treated by 
electricity, massage, passive movements, and fixation in a 
straight splint during a period of nine months, without result. 
He was admitted to Maghull Military Hospital, 'April 18, 1917. 

Two days after admission a treatment was given whose 
principle consists in producing a condition of fatigue in the 
muscles responsible for contracture. This fatigue is produced 
by continuous passive movements in a direction opposed to 
the normal action of the muscles in question. Many hours of 
forcible movement are sometimes necessary in the case of the 
more powerful muscles before the limp, toneless fatigue con- 
dition is brought about. Relays of men are told off for this 
purpose. Patients are got to assist in the work, particu- 
larly such as have been cured by the treatment. Also, the 
patient is himself told about the nature of spasms and the 
relief which the method will bring. This patient was told 
that after the flexor muscles were fatigued they would no 
longer be able to pull the fingers into the clenched position, 
whereupon the antagonistic muscles on the back of the fore- 
arm would begin to work. 

The fingers were forcibly opened without interruption for 
six hours, in each case as soon as the fingers closed into the 
palm. In a few hours they began to return more slowly, and 
at the end of the six hours remained extended. The extended 
position was still found the following morning. The exten- 
sor muscles were feeble in action, but improved day by day. 
The spasm did not return. The patient was discharged 
July 2, 1 91 7, about two and a half months after admission to 
Maghull. The hand was now strong and useful. 



TREATMENT AND RESULTS 695 



Bullet through shoulder girdle: Hysterical ad- 
duction of arm. Treatment by induced fatigue. 



Case 490. (Reeve, September, 19 17.) 

A man, 29, was in hospital more than two years before the 
Reeve fatigue treatment was applied to a functional con- 
tracture. This man had a bullet pass through the right 
scapula and out the pectoralis major, June 4, 191 5, was (ac- 
cording to patient's story) operated two months later, then 
further operated for drainage of septic wounds, and from 
August, 191 5, had his arm fixed to the side, going into spasm 
at any attempt to move it passively. The elbow was ex- 
tended and at first the fingers were tightly flexed and wrist 
extended. The finger flexion and wrist flexion cleared in 
March, 191 7, and recurred in May. Electrical massage in 
June, 191 7, yielded free movement, but the spasm returned. 

The man was admitted to Maghull, June 12, 191 7, that is, a 
little over two years after his injury. The arm sprang back to 
the side like a clasp knife on being released. The wrist and 
fingers were moved freely. Three days after admission the 
elbow was forcibly flexed for some hours, whereupon the spasm 
disappeared. Next day the arm was forcibly abducted and 
reabducted: for four or five hours the arm could be volun- 
tarily abducted. Two assistants were necessary, such was 
the force of the adductor contraction. At the end of a 
week the patient was found able to lift his hand to the back 
of his head. There was no longer spasm. 

Re abrupt treatments, amongst which Reeve's treatment 
by induced fatigue may be counted, Babinski and Froment 
consider that abrupt treatment is far superior to slower 
psychotherapy combined with isolation, whether or not we 
are dealing with a recent or an old disease. So far as psy- 
chotherapy goes, Babinski wants to obtain a definite im- 
provement, if not a cure, on the first application of treat- 
ment. According to Babinski, the patient's faith in his 
physician's power to cure him is most active at this first 
meeting, whose emotionality favors the cure. 



696 TREATMENT AND RESULTS 



Burial and bruises of back : Hysterical cross-legs. 
Treatment by induced fatigue of contractured 
muscles. 



Case 491. (Reeve, September, 191 7.) 

A man, 32, was buried by a shell and bruised about the 
back, August 2, 19 16. He was bedfast until February, 191 7. 
Every attempt to move the legs brought on tremors. He was 
then allowed up; but the attempt to walk caused one foot 
to knock the other, and his ankles became bruised, necessi- 
tating cotton wool pads for feet. 

He was admitted to Maghull, June 12, with one leg crossed 
over the other and the thigh adductors spastic, especially 
on the right. 

The fatigue treatment was carried out in dorsal decubitus, 
each leg being pulled by a man, and the separation repeated 
when necessary. Four hours a day for three days of this 
work finally reduced the spasm so that the patient was able 
to walk with assistance. On the sixth day he walked a mile 
without assistance. The spasm has not returned. 

Re leg contractures, Berard got successful results by con- 
tinuous extension combined with injections of 1 per cent 
novocain into the sciatic nerve trunk and the contractured 
muscles. According to Babinski and Froment, there ought 
to be an almost certain cure of any genuine hysterical state. 
They quote the observations of Souques, Meige, Albert 
Charpentier, Clovis Vincent, Roussy, and Leri as proving 
this claim. 

The Reeve method, so far as it is psychotherapeutic, bears 
a resemblance to Clovis Vincent's first stage of what the 
poilu calls tor pillage, namely, the stage of crisis and of in- 
tensive reeducation. But Clovis Vincent uses in his direct 
and forcible reeducation the galvanic current. 



TREATMENT AND RESULTS 697 



Bullet wound of neck : Hysterical torticollis. Treat- 
ment by induced fatigue. 



Case 492. (Reeve, September, 191 7.) 

A soldier, 20, had a bullet pass through the back of the 
neck, July 10, 19 16, and returned to his depot surgically well 
October 1. A fortnight later a Zeppelin raid turned his 
troop out in the middle of the night, and on the morrow the 
man's neck was twisted around and inclined upon the left 
shoulder. 

Treatment followed in various hospitals, with fixation in 
the corrected position by plaster of Paris but without result. 
The patient was admitted to Maghull, April 18, 191 7, with 
spasm of^ left trapezius and right sternomastoid muscles. 
Under hypnosis the deformity could be easily corrected. 
Unfortunately, it returned. 

The fatigue treatment described by Reeve was started a 
week after admission to Maghull. The neck was forcibly 
straightened and restraightened upon return to its twist. In 
a few hours the contracting muscles had become fatigued; 
the neck was straight. 

The next day the deformity returned slightly. The 
fatigue treatment was repeated. The patient was discharged 
well, July 2. 



698 TREATMENT AND RESULTS 



Burial by shell explosion: Abasia, tremors. Claw 
foot persistent two years cured by induced fatigue. 



Case 493. (Reeve, September, 191 7.) 

A man, 24, buried by a shell, February, 191 5, had had a 
functional " claw foot " for more than two years, cured by 
the Reeve fatigue treatment in less than a week. According 
to Reeve, claw foot is perhaps the most common of the war 
contractures, particularly intractable, and often seen out of 
hospital with an " inside splint." 

After his burial this man could not walk, had tremors, was 
in bed for four months and on getting up showed strongly in- 
verted foot. Three months' splint treatment, strong faradic 
currents, massage, passive movements, special boots with 
leather wedges to tilt the foot over, were methods of treat- 
ment tried, but unsuccessful. At Maghull from November 
18, 1 916, he was treated by exercises, passive movements, 
suggestive and reeducative measures, and after a few months 
got about without sticks. 

The claw foot continued. Toward the end of June, 191 7, 
the feet were forcibly flexed and everted for eight hours. The 
deformity disappeared, but returned slightly next day. Fur- 
ther fatigue treatment for eight hours caused the spasm to 
cease permanently. He was discharged quite normal, July 
20, 191 7. Reeve remarks that this fatigue method might 
be applicable to certain hysterical contractures in civil prac- 
tice. 



TREATMENT AND RESULTS 699 



Skull trauma over 


right eye 


: Delirium, 


febrile ? 


post-traumatic? exhaustive? 


Operation : 


Epilepti- 


form excitement. 


Later, expl 


osive diathesis: Op- 


eration: Euphoria. 


Seizures 


and slight 


mental 


change. 









Case 494. (Binswanger, October, 191 7.) 

A soldier (brother choreic, sister infantile palsy) had had 
measles at 13 and in his fever climbed out of bed upon a 
couch, fell from the couch and was found by his mother 
lying on the floor. He was of moderate intellectual grade, 
of an emotional, passionate Saxon nature and had now and 
then been intoxicated. 

In September, 19 14, he was wounded over the right eye. 
He did not lose consciousness but concluded that he could 
not get back to his own lines on account of the enemy fire. 
Using a knapsack to cover his head, he lay down for twenty- 
four hours, until rescued by a passing body of the sanitary 
corps who were about to leave him for dead when he called 
loudly to them. 

He was very weak in hospital and, towards the evening of 
the day after receiving his injury, he must have fallen into 
some sort of psychotic state lasting ten days. For this he 
remained quite amnestic, although he was told by comrades 
that he had hallucinations and had scolded and yelled, hear- 
ing voices. Apparently there were situation-deliria — the 
call to go over the top. Temperature, which had run to 38.8, 
after ten days sank to normal, and consciousness cleared up. 

Was this a case of protracted febrile delirium? Or of 
psychosis due to commotio cerebri, that is, an effect of height- 
ened intracranial pressure? Or was it exhaustion-delirium 
following loss of blood, sleep and food? 

But this was not the end. The wound suppurated, and 
in May, 191 5, eight months after the injury, operation was 
performed to relieve this abscess. Temperature immedi- 
ately rose to from 38.4 to 38.6, the fever lasting three days, 
and a second psychotic phase with complete amnesia entered. 



700 TREATMENT AND RESULTS 

He went into this phase immediately after recovering from 
the operative narcosis, looking wildly about and cursing the 
sister. The patient was violently excited and was put in a 
straight jacket on the second day. This phase may be re- 
garded as one of epileptiform excitement with delirium. The 
operation may have played a part in the psychosis. 

There were no further psychotic phenomena which could 
be attributed in any way to commotio. There were, however, 
attacks of cortical origin and emotional seizures. The 
patient became emotionally excitable and lost all inhibitions 
against expression of emotion, such as crying. Once he ac- 
tually tried to suppress his emotion with a noose about his 
throat. He became seclusive and withdrew within himself 
— a victim of Kaplan's explosive diathesis, or of Bonhoef- 
fer's emotional hyperesthetic defect condition. 

A second operation was performed in September, 191 6, 
to loosen the brain scar, and a large splinter of bone was 
removed. During the operation, under local anesthesia, 
there was a severe cortical seizure with complete disappear- 
ance of the reflexes. Ether was then administered. Later, 
in the same day, there were several minor cortical attacks. 

After this operation the man's emotional status changed; 
he was no longer irritable or exclusive, but became slightly 
euphoric and contented. He received during the next two 
weeks four tablets of Sedobrol and for a long time thereafter 
two tablets daily. There were never any phenomena of 
bromidism or any suggestive effects of the bromides. 

The first attack after the second operation came in Novem- 
ber, 1 91 6, and was followed by slight dysarthria. Repeated 
attacks followed which were attributed to contractions in the 
scar. Accordingly, a third operation was performed and an 
attempt was made to bridge over a defect in the right frontal 
bone. The man's emotional status remained good after the 
operation, but further attacks appeared six weeks later and 
there were spells of dizziness. Occasionally, in process of 
thinking, he said something stuck in between his thoughts. 
Sometimes thinking broke off sharply as if he had cut through 
a wire with an electrical current in it. There was a slight 
reduction in attention and a slightly increased fatiguability. 



TREATMENT AND RESULTS 701 

/ 



Hard service; shell explosion with loss of teeth: 
Vomiting. Cure by restoration of self-confidence. 



Case 495. (McDowell, January, 1917.) 

A married reservist was called up at the outbreak of the 
war and went through Mons, the Marne, and the Aisne and 
was finally blown up by a shell at Ypres. Early in Novem- 
ber, 1 9 14, he lost his speech but got it back in time to get 
home for Christmas. A number of teeth had been lost in the 
injury. Vomiting began first in England. While on leave 
at home he vomited at every meal. Asked whether it was 
his food or his thoughts, he said, " You are quite correct, 
Sir, you know I have always been with thinking." 

Under medical care, June, 191 5, he was found suffering 
from hesitating speech, general tremulousness and emotion- 
ality. He worried a great deal on account of money matters 
at home. He lay awake thinking. A child became ill and 
died, and all the while he got worse, " thinking all the time." 

It was explained to him that the vomiting was a matter of 
emotions. The lost teeth were replaced by false ones. As he 
began to get control of his emotions, he vomited less and in- 
creased in weight. Finally he was boarded for discharge and 
was sick again on the day of the meeting. A fortnight later 
when sent to sign discharge papers he vomited once more. 

According to McDowell, the vagus may possibly be in- 
criminated as a cause of these gastric disturbances. Prac- 
tically, the vomiting is a result of emotional stress. The 
cure is to produce insight on the part of the patient, the re- 
moval of worry and the restoration of self-confidence. 

Michell Clarke cured such cases with milk diet. 

Roussy and Lhermitte find hysterical vomiting to be rela- 
tively common and as a rule without difficulty in diagnosis; 
but they remark that there is often some underlying organic 
condition to be sought for and treated after the neuropathic 
element has vanished. They remark, also, that there is no 
tendency to spontaneous cure of the disease. They advocate 
a strict dietetic regime and psychotherapy. 



702 TREATMENT AND RESULTS 



Cure of self-accusatory ("started retreat from 
Mons") and other delusions by " autognosis." 



Case 496. (Brown, January, 1916.) 

Capt. William Brown, in the discussion at the Section of 
Psychiatry of the Royal Society of Medicine, January 25, 
19 16, speaks of a method of treatment which he calls autog- 
nosis — a method of giving the patient self-knowledge, by 
revealing to the patient through his own confessions the 
cause of mental change leading to his symptoms. One of 
Brown's examples is that of a sergeant in the firing-line 
during the retreat from Mons. He was admitted to Maghull 
with the delusion that people thought he had given the signal 
for the retreat from Mons on a silver whistle, a shooting prize 
of his. German officers used silver whistles that made a 
note like his own. In fact, he had other like delusions, such 
as that people thought him responsible for an Edinburgh 
railroad accident in connection with his troop-train. A 
German spy might have heard this. 

In the process of procuring autognosis, Capt. Brown found 
that at the age of 12 this man had been falsely accused of 
stealing pork pies from a shop, and had been brought before 
a magistrate. In point of fact, he proved an alibi, but he was 
greatly worried by the charge. According to Capt. Brown, 
this incident of the insistence of the false accusation was the 
beginning of his tendency to delusions. In two months' time 
there was a remarkable improvement. 

Re psychoanalysis, autognosis and various modifications, 
Forsyth remarks that when the acute stage is passed, the 
Shell-shock case becomes an everyday neurosis in which war 
experiences are merely the latest phases in the patient's 
life, and that psychoanalysis may then become necessary. 
Eder regards the "mechanisms" of what he terms "war 
shock" as the Freudian mechanisms of hysteria, and has 
commended psychoanalysis for a few cases, preferring hyp- 
notism for acute cases. Adrian and Yealland decry psycho- 
analysis on the score of time limitations. 



TREATMENT AND RESULTS 7^3 



Deaf mutism in three men shell-shocked at one 
time. 



Cases 497, 498, 499. (Roussy, April, 191 5.) 
There were three Zouaves in a first-line trench north of 
Arras, January 14, 19 15, who were blown up by a bomb thrown 
from the enemy trench some hundreds of meters away, by a 
mortar, a crapouillaud. This projectile burst with a great 
noise, louder than that of a bomb, and made a very strong 
windage. A dozen men were blown under the trench wall, 
just after entering the trench; two were killed; and the 
others, most of whom had been buried to the neck, were 
pulled out and carried, trembling, to the nearest relief post. 
Two of the three Zouaves were bleeding at nose and ears, and 
all three were absolutely deaf and mute. Evacuated to an 
ambulance, and thence to Paris, they arrived at Val-de-Grace, 
January 17, that is to say, three days after the shell burst. 
They communicated with the attendants by signs; one got 
hold of paper and wrote several hours in the day rapid notes 
about the accident. However, hysteria or pure simulation 
was suspected in these three Zouaves, and they were placed in 
small separate rooms. They were informed through the 
physician's remarks to his staff that these were cases of noth- 
ing but simple nervous shock such as we had often observed, 
and the claim was made that they would be completely well 
either on the morrow or the day after. 

On the morrow, two .of them partially recovered hearing 
and got back their voices. They became loquacious and 
began to tell about the battle. The day after, the third 
patient began to speak. Two of them showed traces of 
auricular hemorrhage, and in fact, actual ear lesions were 
found in all three. One had a suppurative right middle ear, 
with perforation; another had both drums perforated and a 
suppurative middle ear, also on both sides. The third, who 
recovered his speech after the others, had perforation of the 
left tympanum with a little suppuration of the right ear 
tympanum and a slight tear of the right tympanum. In 
April, 191 5, the hearing was cured. 



704 TREATMENT AND RESULTS 

These men had been under fire several months, and had 
taken part in the battle of the Marne. It was not a question 
of their first baptism of fire, and in fact, each of them had 
been previously wounded. According to Roussy, the story 
is, that the shell-burst produces by displacement of air tym- 
panic perforation, and at the same time a violent nerve 
shock with loss of consciousness for a few minutes. The 
men come to, but the ear lesion, probably exaggerated by the 
nervous status of its bearer, creates a complete bilateral deaf- 
ness. This deafness produces an absolute hysterical mutism. 

Re case groups of war neurosis, several writers speak of 
dangers of contagion, but also emphasize the values of con- 
tact of patients with one another in the securing of thera- 
peutic results. What Mott has termed the atmosphere of 
cure was no doubt present in the three instances of Roussy 
just cited. The cure of one may act heterosuggestively to 
produce the cure of a second, and so on. Functional deaf- 
mutes are somewhat refractory as a rule. H. Campbell 
states that there is some danger attached to allowing large 
numbers of functional cases to consort together too closely. 
He suggests making use of small wards and screens, and a 
process of sorting out patients so that they shall not affect 
one another injuriously. Steiner especially stresses the value 
of individual rooms in preventing psychic infection, of 
which, he says, the danger is large in open dormitories. The 
psychic contagion is as a rule that of hysterical seizures and 
tremors; but complaints about faulty hospital arrange- 
ments are also readily spread. Steiner advocates never 
questioning a nervous patient concerning his troubles in the 
presence of other soldiers. To reach 60 to 70 patients, 
Steiner had one examining and treatment room. Roussy's 
institution atSalins in 191 7 had a service limited to traumatic 
hysteria, from which, in three months' time, 200 subjects had 
been discharged cured (see Boschi). 



TREATMENT AND RESULTS 705 

— 1 






Dysentery: Milk diet persisted in: Vomiting, in- 
continence, inability to walk. Cure by persuasion. 



Case 300. (McDowell, December, 191 6.) 

A soldier, 25, a low menial when war broke out, developed 
" dysentery and gastritis " at the Dardanelles, although 
even before the dysentery his nerves had gone bad. He had 
diarrhoea and vomiting, was sick every day, found himself 
unable to walk, and found himself always wet with urine 
dribbling day and night. Arriving in England and treated 
in a hospital, he still had vomiting. He had lived on milk 
and custard and been kept in bed. 

Capt. McDowell convinced the patient that his legs were 
not as weak as he supposed. He was encouraged to walk, 
put upon light diet and then upon ordinary diet. He be- 
came an active worker in the ward, later going for five-mile 
route marches. Two months later he went back to duty in 
good health, weighing seven pounds more than before. This 
man was weakminded and, when his dysentery was cured, 
did not dare to start eating ordinary food. He was a victim 
of hospital regime. Individual attention would have obvi- 
ated much of the subsequent state. 

Re vomiting, see remarks under another case of McDowell 
(Case 495) - # 

Re incontinence, see Case 384, of Guillain and Barre. 



706 TREATMENT AND RESULTS 



Officer dies in convulsions : Servant develops hys- 
terical convulsions, which vanish on being ex- 
plained as such. 



Case 501. (Hurst, March, 1917.) 

An officer and his servant were blown up by a shell. The 
servant ran to fetch a stretcher for the officer, to whom he was 
much attached, but on his return the officer made a few 
convulsive movements and died. Immediately after, the 
servant had a fit. During the next two months he had eleven 
more. Hurst made a diagnosis of hysterical fits resulting 
from emotion, explained his idea of their origin and nature 
to the servant, and the convulsions then ceased completely. 

Re hysterical convulsions, see remarks under Case 443. 



Course of a case with crises of trembling. 



Case 502. (Roussy, April, 1915.) 

A soldier in the artillery, who had been in the lines from 
August as a kitchenman, looking after the food of the first 
line trenches, with which his shelter was connected by com- 
munication trenches, 800 meters away, was on January 17, 
191 5, with three other men placed in the shelter kitchen of 
the trenches but a short distance away from the French ar- 
tillery. The firing passed over the heads of these men but 
they could feel the windage, which obliged them to lie down 
each time. The evening of that day, several hours after 
firing had ceased, the kitchenman had a shivering spell, with 
trembling that lasted all night ; after which these crises came 
on every day. He had finally to be evacuated to the rear. 

According to Roussy, such patients always have neuro- 
pathic taint and a history of previous crises. Such a patient 
ought to be handled with rather severe discipline. In this 
way, according to Roussy, the reappearance of a severe attack 
of convulsions can be prevented. But these patients cannot 
go back to the front. 

Re tremors, see Cases 224 and 225. 



TREATMENT AND RESULTS 707 



Two cases of lameness cured by persuasion 
Russel. 



Case 503. (Russel, August, 191 7.) 

A man on crutches, paralyzed completely in the right leg, 
partially in the left, developed paralysis in the right arm 
from the use of the crutch. There were marked vasomotor 
changes in the right leg and arm together with anesthesia 
to pinprick. Assured that he could move the legs perfectly 
he said that he had tried and failed. After a persuasive talk 
in private he began to use the arm, and to walk perfectly. 
It seems that in the trenches he had a sharp pain in the 
right knee, after which he did not use the leg and it gradually 
became more and more useless. It had been paralyzed for 
three months. The reason he did not use this leg was not 
on his own account, but on account of his mother at home. 
He seemed really grateful for the cure. 

Case 504. (Russel, August, 1917.) 

A sergeant in hospital for a year for shell-shock still had 
a marked shaking of the right leg whenever he raised it from 
the ground. He walked in leaning on a silver headed cane. 
The functional nature of his shaking was explained to him 
by Russel, whereupon he walked out normally saying he 
could do without his cane. Russel suggested that crutches 
and sticks thus given up were often donated to the shrine. 
The sergeant whose cane must have cost at least three pounds 
beat a hasty retreat carrying the cane in front of him. 

Re Russet's general point of view concerning malingerers 
and psychogenic cases, see under Case 458. 



708 TREATMENT AND RESULTS 



Hard patrol work: Delirium; head tremor aug- 
mented by excitement: Virtual recovery on ban- 
daging neck, isolation, open air, to-and-fro transfers 
to mental and nervous wards. 



Case 505. (Binswanger, July, 1915.) 

A metal moulder in civil life, 29, in military service 1907 
to 1909 (no hereditary taint, moderately good scholar), 
became unconscious for a half hour after taking a cold drink 
following a somewhat long practice march, at some time dur- 
ing his first year of military service. 

He was in several skirmishes in Belgium and Northern 
France early in the war, being once surrounded in patrol 
work (November 11) by Turcoes and Zouaves. There was 
a lively exchange of shots, in the course of which five of 
the eight men on patrol fell. The three survivors hid them- 
selves for three days in a quarry, and on the fourth were 
found by the advancing troops, and immediately went into 
battle. 

But during a pause while on the point of taking coffee, the 
man suddenly fell sick, tried to carry on, but lost conscious- 
ness and apparently remained unconscious for about three- 
quarters of an hour. It seems that he raved and shouted 
and tried to bite his fingers, being held with great difficulty 
by several comrades. He was removed to a dressing-station 
three km. distant. 

At the dressing- station, his head began to shake, although 
he was unaware of this until his attention was called to it by 
his comrades. He said that he felt restless and that his head 
ached almost continually. He was carried to the reserve 
hospital, and from thence, December 9, 19 14, to the nerve 
hospital at Jena, where he was unaware of the shaking of his 
head (which had now lasted for three weeks), and said that 
he felt a thick fog in his head (to say nothing of headaches), 
and was only free and clear in his head while standing in the 
open air. 






TREATMENT AND RESULTS 709 

His sleep was restless and poor ; there were war dreams al- 
most every night. In the process of getting to sleep, his 
arms and legs frequently twitched. He would soon tire and 
feel weak. Also since his dangerous experience, he had 
noticed a change in his speech: always fluent before, it was 
now hard for him to speak because one had to exert one's 
head so much in speaking. 

This head tremor was in fact the most marked symptom 
of his illness. It would increase on every active motion of 
the head, but ceased almost entirely when attention was di- 
verted. The head would then be held bent to the right. 

During emotional excitement, the shaking spasm would 
spread over the entire upper part of the body, but would 
remain more severe upon the right than upon the left side. 
The forearms would fall into a lively shaking movement of 
pronation and supination. The hands and fingers would be 
attacked by a less marked tremor. After calm had set in, 
a fine tremor of the right hand would remain plainly notice- 
able. The musculature of facial expression would frequently 
fall into spasmodic movement, the left corner of the mouth 
twitching, the lips set for whistling, or the upper lip making 
movements as if snuffing spasmodically. 

Physically the man was of medium height, strongly built, 
with adherent lobules, and a somewhat pointed skull. The 
teeth were defective and irregularly placed. Both deep and 
skin reflexes were increased. Marked dermatographia and 
mechanical excitability of the muscles: periosteal reflexes 
strongly developed; numerous pressure points in the head. 
The right temple and back of the head were painful on per- 
cussion. The patient showed no disturbance in touch and 
pain sensibility. Outstretched tongue showed marked fibril- 
lary twitching; speech was difficult, being slow, awkward, 
stumbling, and sometimes hesitating (suggesting the speech 
of general paresis). At other times, the speech was of a 
peculiar sighing, tremulous nature, reminding one of the 
speech of children complaining or asking for pity. Rest 
was secured by injections of salt solution. A few days later, 
the treatment was continued by a bandage about the neck. 
After this the tremor grew slighter and would even remain 



710 TREATMENT AND RESULTS 

absent for some hours. The patient was told to rest in bed 
and not to speak much; being " seriously ill," he was kept 
alone. He was often irritated, querulous, and subject to 
outbursts of profanity. He took food well and slept well, re- 
ceiving sodium bicarbonate. 

The bandage was changed after five days. The tremor was 
very marked. The patient was furious because visitors were 
refused to him. He was especially angry with his nearest 
relatives and his betrothed, and wrote defiant letters to all 
of them. He became one of the most troublesome patients 
in the psychiatric division of the hospital. He complained 
sometimes of anxiety and feelings of unrest. He received 
treatment by pantopon. He continued to be a very disa- 
greeable patient, feeling himself opposed and not properly 
considered. He thought himself seriously ill, behaved much 
like a spoiled child, and was of the opinion that he would not 
get well in the hospital because they were grieving him so. 
His appetite became bad; he complained of pains in the 
loins and of rheumatism in the legs. A cord was found 
hidden in the bed. The patient expressed suicidal thoughts 
at various times. 

At the beginning of January there was marked improvement. 
The headshaking ceased almost entirely; the patient walked 
in the garden some hours daily. However, in the middle of 
January, on refusal of furlough, the head-shaking began again 
markedly. At his request a bandage was placed on the head 
again for a few days. He seemed emotionally very tender; 
his head would shake at the sight of a dead rabbit. 

He was transferred to the nerve division of the psychiatric 
clinic at the end of January. He had recently begun to 
complain of flickering before the eyes. The ophthalmolo- 
gists established an existence of a choroiditis disseminata. 
The eye examination had a markedly depressing effect upon 
the patient, and the shaking spasm of the head appeared 
again. Upon being told that he would have to be sent back 
to the psychiatric section of the clinic, the shaking immedi- 
ately disappeared (24 hours after it had begun). 

Thereafter slow improvement followed. He stayed in the 
open a great deal and walked. March 2, he showed a ve- 



TREATMENT AND RESULTS 



711 



hement outburst of anger, quarreling and using violence 
with a comrade. He was brought back to the psychiatric 
section, and in transit had a severe hysterical attack with 
unconsciousness, crying fits, and stepping movements of the 
extremities. He was promptly taken to a section for those 
seriously ill. The next day, upon his assurance that he could 
control himself, he was put in a more quiet division. He 
began to take part in gymnastic exercises, worked as a coach- 
man, and then as an experiment was sent to a gentleman's 
estate for recreation. At last accounts he was feeling well 
except that he occasionally had headaches during work. He 
could not work so hard as before on account of the rapid onset 
of fatigue, especially when working in the sun. The head- 
shaking recurred but seldom and lasted for a few hours only 
when the patient became angry or when there was much noise 
about. 



712 TREATMENT AND RESULTS 



Rationalization of war memories: Returned to 
duty. 



Case 506. (Rivers, February, 1918.) 

A young English officer was wounded just as he was ex- 
tricating himself from burial in a mass of earth. He became 
nervous and sleepless and lost his appetite. After the 
wound had healed, he was sent home on leave, which had to 
be extended as he got worse. An out-patient in London for 
a time, he was finally sent to a convalescent home, still 
troubled with insomnia, battle dreams and concern about his 
recovery. He made light of his condition and was on the 
point of being returned to duty by the medical board, when 
his sleeplessness led to his being sent to Craighlochart War 
Hospital. 

He could not sleep without a light in the room, else every 
sound attracted his attention. He tried hard all day long to 
banish all unpleasant and disturbing thoughts, but at night 
it took him a long time to get to sleep and then came vivid 
dreams of warfare. He did not, himself, feel that he could 
ever forget the war scenes. 

Rivers, in general believing that the attempt to banish 
such experiences absolutely from the mind is poor psycho- 
therapy, narrated his views to the patient Rivers advised 
him no longer to try to banish the memories, but to try to 
transform them into tolerable, if not pleasant, companions. 
The war experiences and anxieties were talked over. That 
night the man had the best night he had had for five months, 
and during the following week the sleeplessness was no longer 
so painful and distressing. If unpleasant thoughts came, 
they had to do rather with home life than with the war. 
General health improved; insomnia diminished. He was at 
last able to return to duty. 



TREATMENT AND RESULTS 713 



Rationalization of war memories. 



Case 507. (Rivers, February, 1918.) 

An English officer was buried by shell explosion and de- 
veloped severe headache, vomiting and disorder of micturition, 
yet remained on duty for more than two months. Collapse 
came when he went out to seek a fellow officer and found the 
body blown to pieces, with head and limbs severed from 
the trunk. This vision haunted him in dreams. Some- 
times the officer appeared as on the battlefield; again as 
leprous. The officer would come nearer and nearer in the 
dream, until the patient woke pouring with sweat and in 
utmost terror. Accordingly, he was afraid to go to sleep, 
and spent all day thinking painfully about the night to come. 
Advice to keep all thoughts of war out of mind merely brought 
the memories in sleep upon him with redoubled force and 
horror. 

Rivers' therapy was to draw attention to the fact that the 
terrible mangling proved conclusively that the officer had 
been killed outright and without pain. The officer said he 
would now no longer attempt to banish the thoughts and 
memories of his friend, but would concentrate on the pain and 
suffering his friend had been spared. No dreams at all came 
for several nights, but one night in his dream he went out 
into No-Man's-Land and saw the mangled body, but without 
horror. He knelt down, as he had in the original experience, 
and woke as he was taking off the Sam Browne belt to send to 
the relatives. A few nights later came another dream in 
which he talked with his friend. There was but one more 
dream in which horror occurred. 






714 TREATMENT AND RESULTS 



Rationalization of war memories : Eventually un- 
fitted for military service. 



Case 508. (Rivers, February, 1918.) 

A young English officer, after doing well for a period, was 
rendered unconscious by shell explosion. The first thing he 
remembered was being led by his servant towards his base, 
thoroughly broken down. He had headaches, sleeplessness, 
war dreams and spells of terrible depression appearing with 
absolute suddenness, unlike ordinary " blues." For ten days 
in hospital no such attack appeared, but one evening he came 
to Rivers pale and anxious. A few minutes before, he had 
been writing a letter in his usual mood, when this causeless 
depression came on. In the afternoon he had walked about 
on some neighboring hills. The letter dealt with no de- 
pressing matter. In ten minutes the depression vanished. 
Nine days later another came as he was standing idly looking 
out of a window. The attack lasted for several hours, as no 
physician was present to meet the issue. If he had had a 
revolver he would have shot himself. 

Rivers was inclined to interpret these gusts of depression 
as due to a forgotten but active experience. As there was 
no definite tendency to dissociation, Rivers hesitated to 
plunge in with the hypnotic method, nothing short of which, 
however, served to recall the incident. The man was gravely 
apprehensive about fitness for further service, and was re- 
pressing his fear, as he thought it either was cowardice or 
would be called cowardice. The patient, by his discussions 
with Rivers, had already become familiar with the idea that 
the gusts of depression might be due to a submerged expe- 
rience. Perhaps, however, there had been no experience, 
and the patient was advised that possibly the thing repressed 
was the idea about fitness for service. Accordingly, the 
patient agreed to face the situation. One transient attack of 
morbid depression occurred, after an operation. Then the 
man fell into a state of anxiety neurosis such that he was 
passed by a medical board as unfit for military service. 



TREATMENT AND RESULTS ?l5 



Rationalization of war memories: Commission 
relinquished. 



Case 509. (Rivers, February, 1918.) 

An oldish English officer lost consciousness while looking 
at the havoc wrought by shell explosion. Probably there was 
a second shell that sent him off. He was eventually admitted 
to an English hospital with paresis and anesthesia of legs, 
severe headache, sleeplessness and terrifying dreams. Hyp- 
notic drugs and advice neither to read nor to talk about the 
war were the measures adopted and after two months in 
hospital he was given three months leave. He buried him- 
self in the heart of the country, away from relatives, with 
aspirin and bromides. He began to sleep better and had 
less headache. When the president of the medical board 
asked a question about trenches at the end of his period of 
leave, however, he broke down and wept. He again re- 
paired to the country for two months' leave, for the chosen 
treatment by isolation and repression. 

An order was then given that all officers must be either 
in hospital or on duty. He was sent to an inland watering 
place and treated by baths, electricity and massage, where- 
upon he rapidly became worse, especially as to sleep. He 
was transferred to Craiglochart in an emaciated state, with 
an expression of anxiety and dread, paresis of legs, sleep- 
lessness and war dreams. 

He was now advised to give up repressing, to read and 
talk a little about the war, and to accustom himself to think- 
ing about war experiences. He did this but half-heartedly, 
as he thought the ideal treatment was what he had so long 
followed. Nevertheless, he got distinctly better and the con- 
tent of the war dreams was altered to home scenes. He was 
still loath to acknowledge his improvement and thought that 
he would have recovered if he had not been taken from his 
retreat and sent to hospital. As it was obvious that he 
would be of no further use in the army, he was allowed to 
relinquish his commission. 



71 6 TREATMENT AND RESULTS 



Rationalization of war memories, without redeem- 
ing feature as nucleus. 



Case 510. (Rivers, February, 1918.) 

An English officer was flung by shell explosion so that his 
face struck the ruptured and distended abdomen of a dead 
German. The officer did not immediately lose conscious- 
ness and got distinct impressions of taste and smell and an 
idea of their source After a period of unconsciousness he 
came to, vomiting and much shaken. He carried on several 
days, still troubled by vomiting and haunted by taste and 
smell images. Several months later he was observed by 
Rivers suffering from horrible dreams, in which the battle 
experience was faithfully reproduced. He got no relief ex- 
cept when he went into the country, far from every sugges- 
tion of war. Rivers' psychotherapeutic plan of finding a 
redeeming feature in the experience, upon which the patient 
might concentrate, failed because there was no redeeming 
feature. Accordingly, it was thought best that the man 
should leave the army and seek the conditions that had 
given him slight relief. 

Re psychoanalysis and its modifications, see remarks under 
Case 496, under which several favorable opinions were men- 
tioned. Boschi in his report on French conditions gives no 
reference concerning psychoanalysis or hypnosis. Bruce 
has found blended with the war dreams many episodes quite 
alien to the war, and considers that the patient's ante-bellum 
history is of importance, since ante-bellum emotions may 
be revivified by the war. Craig states that he has not been 
impressed favorably by the results of psychoanalytic treat- 
ment. Arinstein from Russian experience gives preference 
to Dubois' psychotherapy over hypnosis and psychoanaly- 
sis. Nonne states that the data of the war prove that 
hysteria is neither a degenerative disease according to classi- 
cal theory, nor a disease based upon Freudian principles. 



TREATMENT AND RESULTS 717 



Post rheumatic " paraplegia " (or abulia?) cured by 
removal of crutches, after question of discharge 
" unfit " had been raised. 






Case 511. (Veale, November, 1917.) 

A soldier, 23, had fever with swelling of several joints 
and temperature in 191 5, and was furloughed to England. 
He complained of pains in the limbs and shortness of breath, 
and was put in hospital. As he did not improve, he was sent 
to a special hospital for baths and electricity. There he 
remained from August, 1915, to March, 1916, with D'Arsonval 
baths, cataphoresis, electric treatment and massage. 

He was now sent to the second Northern General Hospital 
to see whether he should be discharged permanently unfit. 
Here he shuffled along on two crutches, very tremulous, and 
sweating, and suffering from palpitation on exertion. He 
wanted to take poison if he could not be cured. 

The crutches were taken away. He was asked to walk up 
and down. He had to be supported at first and fell several 
times. The exercises were continued. Massage and drug- 
ging were stopped. The next day he was able to stand 
alone. In twenty-four hours he walked by himself. The 
other patients in the ward encouraged him on account of the 
genuine exertions he was making to get well. April 7, he 
returned to duty, smart and well set up. 

Babinski and Froment always give the suspected subject 
the benefit of the doubt, never uttering the word simulation 
in the presence of the soldier, and proceed to psychotherapy ; 
for psychotherapy will act to cure simulation or exaggeration 
just as it acts to cure hysteria. They say that in their expe- 
rience, all these disorders of doubtful nature — that is, that 
lie diagnostically between hysteria, exaggeration, and simu- 
lation — are as a rule cured by resort to psychotherapy pro- 
vided that the due amount of energy, tact, and perseverance 
is employed. See also remarks under Case 453. Veale's 
case (511) never showed mauvaise volonte, and nothing more 
than aboulia. 



7l8 TREATMENT AND RESULTS 



" Trench foot," " neuritis," a year of astasia-abasia 
or at least of complaint of inability to stand or walk. 
Treatment by a " cruel though justifiable " process. 



Case 512. (Veale, November, 191 7.) 

A regular army man, 38, well built and muscular, in 
Flanders the first winter, returned to England in January, 
1915, with "trench foot." "Neuritis" then developed, with 
loss of power to walk. Baths, electricity, massage, sym- 
pathetic wheeling about in a chair by women, all failed. 

January 11, 1916, he still complained of inability to walk 
or stand. The reflexes were exaggerated. He was able to 
get into a wheel chair from bed by jerks, associated with 
palpitation, tremors, flushing and sweating. 

He was told that he had now recovered from the neuritis. 
Crutches, sticks and wheelchair were removed. He flopped 
about and then lay on the bed exhausted. In a few days he 
began to shuffle about and was put on the stationary bicycle. 
January 29, he left the hospital well, remarking that though 
the treatment at first seemed cruel, it was fully justified. 

Re genuine polyneuritis, Mann gives German experience 
regarding neuritis as somewhat frequent and affecting a 
special form which he terms polyneuritis neurasthenica. He 
states that the commonest instances of mononeuritis devel- 
oping in the war are the sciatic and trigeminal. The neuritis 
often outlasts the other symptoms. The treatment was rest, 
tepid baths, and electricity. Naturally, alcohol and syphilis 
must be excluded in the diagnosis. 

Nonne also described non-alcoholic, non-syphilitic, and 
non-infectious polyneuritis in neurasthenics, which he, how- 
ever, finds most common in the ulnar, median, radial, an- 
terior crural and posterior tibial nerves. 

Re "spa" treatment, Turner thinks there may be easily 
too much massage, electricity, bathing. He prefers segrega- 
tion in special hospitals to "spa" measures in general hos- 
pitals, prefers occupation to rest, and calls attention to the 
stimulating value of the gratuity to be paid on leaving the 
hospital. 



TREATMENT AND RESULTS 719 



Shell-shock paraplegia: Treatment by bed, ciga- 
rettes and chocolates altered to isolation, no 
tobacco, no visitors, faradization. Recovery. 



Case 513. (Buzzard, December, 1916.) 

Early in the war, a lad, 19, was blown up by a shell. He 
was sent home paralyzed from waist down, and was seen by 
Capt. Buzzard after he had spent ten months in various 
hospitals, "carefully nursed, on the water bed, constantly 
using a bed urinal, smoking innumerable cigarettes, and eat- 
ing countless chocolates." He could not move his legs. 
They were wasted and flaccid. The knee-jerks could be got 
with difficulty. Plantar reflexes flexor. Complete anesthesia 
from umbilicus downwards, but preservation of abdominal 
reflexes. The navel did not shift downwards when the 
patient attempted to sit up. The incontinence was not real ; 
urine was passed into the urinal at appropriate intervals. 

Buzzard directed treatment "not to his spinal cord but to 
his mind; isolation; the stoppage of tobacco and all visits; 
the assurance that he would rapidly get well, together with 
some suggestive faradization of his legs." This brought 
about a cure in a very short period. The atrophied legs 
eventually grew strong enough to walk. 

Re cigarettes in Shell-shock, Mott decries the over-liberal 
gifts of cigarettes that induced cigarette habits in both 
officers and men. Of course, the cigarettes are still more 
detrimental to cases of soldier's heart than to other cases of 
neurosis. Mott remarks how over- frequent are the social 
tea-parties, joy rides and drives given by well-meaning ladies 
for the "poor dears," actually perpetuating neuroses. 

Re atrophy, Babinski and Froment again bring up the 
question whether muscular atrophy can be brought about 
by a hysterical motor disorder. In point of fact, Charcot 
and Babinski were the first to describe the true hysterical 
amyotrophy, but this hysterical amyotrophy is exceptional 
in hysterical paralysis, and is slight when it occurs. 



720 TREATMENT AND RESULTS 



Shell-shock blindness, mutism, deafness: Blind- 
ness spontaneously vanished, 24 hours. Mutism, 
2-3 months. Deafness cured by " small operation." 



Case 514. (Hurst, September, 1917.) 

A lance corporal, 26, became blind, deaf and dumb, though 
without losing consciousness, when blown up by a shell, 
August 29, 19 1 6. His sight returned next day. On reaching 
England he talked in his sleep. Encouragement, electricity, 
etherization failed to effect improvement. One night in 
November he woke up and asked the sister for a drink; 
thereafter he talked normally. 

Seven months after the shell explosion he was transferred 
to the neurological section at Netley, March 21, 191 7. Deaf 
to air and bone conduction, a loud noise behind him caused 
a slight tremor of hands, with blinking and dilatation of pupils ; 
but further stimuli of the same sort failed to produce such 
reactions. Normal nystagmus and giddiness on functional 
tests of vestibular nerve and canals. The internal ear was 
then probably free from organic changes. Since shell-shock 
mutism is always hysterical, it was probable that the deaf- 
ness was hysterical. Under hypnosis (staring at lines for 
fifteen seconds) he showed no change. During natural 
sleep, also, a shout of "Fire" and metallic noises failed to 
wake the patient or to produce contraction of eyelids. Elec- 
tric suggestion (despite the patient's belief in electricity) and 
reeducation failed. 

April 16, he was told that a small operation would have to 
be done April 20. To this he readily consented. Two small 
incisions were made behind the ear under light ether and 
suture was inserted. A loud noise was made during the 
''operation"; he heard this noise and jumped from the 
table. To his intense delight normal hearing returned in 
a few minutes. Next day hearing was tested and found 
normal to air and bone conduction. He was discharged to 
duty three weeks later and on his way to France, June 29, 
demonstrated his normal hearing to the physicians. 



TREATMENT AND RESULTS 721 



Deafness : cure by stimulating vestibular apparatus. 



Case 515. (O'Malley, May, 1916.) 

A private, 20 years of age, lost speech and hearing after 
the battle of Neuve Chapelle. Eight days later he came 
under the care of the laryngologist in a very excited state, 
pointing to lips and ears and carrying a note with informa- 
tion concerning his deafmutism. 

Dr. O'Malley wrote on a piece of paper that he would re- 
store the patient's speech and hearing. Dr. O'Malley then 
used the mirror until the point of retching, and wrote, " You 
can speak now; count up to ten loudly." He did. 

Dr. O'Malley next used the cold water douche to the right 
ear to the point of giddiness, then shouting through a speak- 
ing-tube (see description below). The patient then found 
he could hear and the tears streamed down his face. There- 
after he was able to converse freely. Dr. O'Malley writes: 

The treatment of functional deafness consists in ex- 
citing the vestibular apparatus as follows. Cold or hot 
water is allowed to flow in a steady stream into and out 
of the external auditory meatus by means of a tube 
attached to a receptacle placed about one and a half to 
two feet above the patient's head and continued until 
he becomes very giddy and an active nystagmus is pro- 
duced. A speaking-tube three feet long is then used 
by placing the ear-piece in the ear so treated, and the 
surgeon shouts into the mouth-piece the assertion, 
"You hear now," and the answer, "Yes" comes 
promptly. The tube is now dropped and a conversa- 
tion held as if no deafness ever existed. So far I have 
found the treatment of one ear sufficient. The patient is 
usually very emotional, as the disturbed vestibular func- 
tion, which in these cases responds easily and markedly, 
causes him to feel as uncomfortable as a bad sailor on a 
stormy voyage. This feeling, however, rapidly gives 
way to one of pleasure at the return of his hearing. 
Where functional deafness and mutism co-exist it does 
not appear to be material which is treated first. In two 
cases of this kind under my care I treated the loss of 
voice first. 



722 TREATMENT AND RESULTS 



Bullet through mouth ; Hysterical mutism. Treat- 
ment by operative manipulation. 



Case 516. (Morestin, January, 191 5.) 

A Colonial infantryman, 32, was wounded December 17, 

1 9 14, at the Boisselle, being struck by a bullet which entered 
on the right side in the upper part of the neck and came out 
behind the left side of the mouth, having traversed the 
tongue, broken two teeth, and caused a good deal of hem- 
orrhage by mouth. The patient felt his tongue swell, and 
from this time on he could not pronounce a word. He was 
sent to the ambulance, then to Mien, then to Saint Germain, 
and finally to Morestin's surgical service. With wounds by 
this time healed, the patient found it hard to open his mouth. 
There was no trace of fracture of the lower jaw. The tongue 
could be only incompletely examined. The man swallowed 
liquids easily but could take no solid food. He tried hard to 
speak, made pantomime movements, grew emotional and 
lachrymose. 

On the whole, however, it seemed that his inability to 
articulate sound could not be due directly to the lesion. 
There must be either simulation or hysteria. For four days 
he was attentively watched, and not once did he pronounce a 
word. He grew more and more stricken and humiliated 
by his plight. Rigorous diet did not cause his mutism to 
cease. Isolation and ennui did not decide him to talk. Ac- 
cordingly, it was announced, in the man's hearing, that an 
operation was to be done to restore speech. January 9, 

191 5, his face was copiously washed with alcohol and ether. 
Cocaine was injected to secure anesthesia and resolution of 
the muscles of mastication. Six c.c. of a 1-100 solution on 
each side. Shortly the surgeon began to open the jaws, 
against decreasing resistance. The tongue, which was not 
spastic, was seized with a tractor and rhythmic movements 
were executed with it. After a few of these movements, joy 
was painted on the features of the patient. He said that he 
wanted to speak and that he was about to speak. He shook 



TREATMENT AND RESULTS 723 

the surgeon's hands effusively and said, "Merci." Although 
the first words came hard, little by little speech became free 
and a perfectly sincere elation at having recovered speech 
set in. 

This man was neuropathic, having always been a rather 
strange, irritable and restless person, and given to nervous 
crises in anger, in which he lost consciousness entirely. 

Re pseudo operations as forms of disguised persuasion, 
almost countless methods have been used. See Cases 514, 
515, 518, 519, especially 521, 560, 561. Sham injections 
under ethyl chloride have been made (Goldstein). See also 
under Case 484, re continuous bath, and under Case 488, re 
lumbar puncture. Very close to these methods are the 
methods of torpillage of Vincent and the methods employed 
by Yealland in England and Kaufmann in Germany. See 
under Cases 574, 563, and 564, and 570. 

Leri quotes Babinski as saying, "We cannot fight hysteria 
in trench warfare; manoeuvres are necessary." 

Re treatment of mutism, Chavigny remarks that the 
principle of treatment for mutism is quite different from 
the principles of treatment of paralysis. The reeducation 
of mutism is psychic. Chavigny claims probably absolute 
success in the treatment of mutism through faradism to the 
larynx region simultaneously with a signal given to the 
patient to make an effort to pronounce the letter A. Garel 
modifies the treatment (in case the faradic apparatus is not 
at hand), by a vigorous and sudden blow to the patient's 
epigastrium simultaneously with the patient's endeavor to 
imitate the movement of the doctor's lips. 



724 TREATMENT AND RESULTS 



Shell-shock: Impairment of vision (even com- 
manded men to fire on kindred troops!) Improve- 
ment by verbal suggestion, faradization, injections. 



Case 517. (Mills, October, 1915.) 

A sergeant-major, 29, in private life a bookkeeper, said 
that shrapnel struck the ground in front of him and burst as 
it struck. Unconscious for a moment, the sergeant-major 
thereafter saw everything imperfectly, led his men in the 
wrong direction, and even commanded them to fire in the 
direction of his own troops. 

Seven days afterwards the eyes looked normal, fundi were 
normal, vision was reduced to the perception of hand move- 
ments; with a plus 10 sphere the right eye could count fingers 
at r 5 cm. and with a plus 8 sphere the left eye could count 
fingers at 3 cm. There was a right frontal analgesia. 

Treatment: Sweating; rest in bed for several weeks; as- 
surance of complete recovery. There was a slow but con- 
stant improvement, aided by faradization and injections of 
strychnine sulphate into the temporal region, but the pros- 
pect of a return to the front retarded the improvement. 

Re injections into the temple, see also Case 521 of Bruce. 
Re cure of blindness, Grasset has a case of a blind deafmute 
who was cured by a nurse. She put a pencil in his hand 
and guided the pencil while she wrote a question. The 
patient replied in very good MSS. In blind deafmutes sight 
is described as returning first, hearing next, and speech last. 

For other cases of blindness, see especially under Section C, 
Cases 433 to 438, with discussions thereunder. 

Re retardation of improvement by the prospect of further 
military service, Lewandowski has insisted upon the strong 
factor of the wish in all such functional conditions. Lew- 
andowski wants all functional cases, however, to be sent to 
duty in the rear or to be discharged as unfit. 



TREATMENT AND RESULTS 725 



Aphonia : manipulation in larynx. 



Case 518. (O'Malley, May, 1916.) 

A corporal, 28, had a bullet pass through his neck from a 
point in the middle line at the upper border of the thyroid 
cartilage to a point behind the right sternomastoid muscle, 
two inches below the point of entry. The corporal lost his 
voice at the time of injury, spat up a teaspoonful of blood, 
and thereafter was able to whisper only. The laryngoscopic 
examination betrayed no intralaryngeal lesion. Treatment 
as described below enabled the patient to speak. O'Malley 
describes his technique as follows: 

The patient is placed in the common position for the 
examination of the larynx, the tip of the tongue being 
seized in a piece of linen by the left hand fingers and the 
laryngeal mirror introduced with the right hand. The 
patient is then requested to say "e " or cough, and if 
the cords do not approximate, they can be made to do 
so by using moderate friction on the fauces and pharynx 
with the mirror to excite secretion. The latter begins 
to drop into the larynx, and acting as a foreign body, a 
protective reflex is at once excited which adducts the 
cords to prevent the secretion from entering the tra- 
chea. At the same time an involuntary cough is pro- 
duced to expel the mucus, and if the friction and flow 
of secretion are maintained and the patient is urged to 
cough vigorously, voluntary coughing and a tendency 
to retching with forced laryngeal notes will rapidly 
follow. It is usually best to persist until retching 
occurs, as the cords are then forced together to protect 
the larynx and trachea from the possible entrance of 
regurgitated stomach contents. Involuntary laryn- 
geal sounds are thus produced and the patient is con- 
scious of laryngeal effort. Some of these cases are at 
the moment very shallow breathers, which can be dem- 
onstrated by X-ray screening, but the act of retching 
causes a wide excursion of the diaphragm with a more 
pronounced expiratory blast, to be rapidly followed by 
deeper inspirations. This method of treatment is best 
carried out just before a meal, as the stomach is then 
practically empty and the unpleasant effects of the 
sudden regurgitation of food are avoided. When the 



726 TREATMENT AND RESULTS 

explosive sounds accompanying retching have occurred 
two or three times the mirror is withdrawn, the tongue 
released, and the patient is requested to swallow, take 
a deep breath, and cough, and then urged to count up to 
ten, directing his voice to a certain point on the ceiling. 
This method has given me uniformly good results, and 
was rapidly effective in all cases coming under treat- 
ment soon after the onset of the neurosis. 

Re methods for curing aphonia, Muck has a method called 
the "ball" method. A ball is put into the larynx to cause a 
temporary suffocation, which produces a reflex that starts 
the adductors. He would apply the method as soon as the 
man was well over the shock that produced aphonia. Muck 
states that he has applied the ball method, not only to cases 
of aphonia, but to cases of mutism and deafness, with success. 

Tilly mentions a case in which the patient refused to open 
his mouth, so the device was adopted of passing an electrode 
through the left nostril so that it finally reached the larynx. 
A spasm was produced, which was carried to the point of 
considerable cyanosis, but the aphonia was relieved and for 
the first time in three months the man spoke. Incidentally 
he began to hear also. 

Re treatment of aphonia, Schultz has used the electric 
current externally over the larynx, all the while carrying 
on a laryngoscopy. Schultz remarks upon the fatigue that 
may come during the first few sittings. Roussy and Lher- 
mitte remark that, although aphonia sometimes exists from 
the outset of shock, it is often a phase in recovery from 
mutism. 

Liebault notes that, not only cases of true nervous aphonia 
but cases of laryngitis, apparently of infectious origin, and 
cases of true voice strain, may also turn up for treatment. 
Some men have been improperly discharged from the army 
for aphonia actually due to voice strain. 



TREATMENT AND RESULTS 727 



Hysterical aphonia in a mechanician (war time 
contributory?). Cure by suggestive manipulation 
of larynx. 



Case 519. (Vlasto, January, 191 7.) 

A mechanician was refitting an engine valve, when steam 
was suddenly put on and the drains were opened out. Some 
of the steam entered the throat of the mechanician, who 
rushed up, gasping, unable to speak. Oedema of the larynx 
was thought of; but there was no complaint except the in- 
ability to speak. 

A month later he was discharged to the hospital ship at 
Plassy, where he got faradic treatment, the effect of which 
was to cause him pain without recovery of voice. The man 
could whisper well enough and cough fairly loudly. The 
vocal cords of the larynx appeared normal on laryngoscopic 
examination, but adduction of the cords was not be properly 
effected. He was now given rest and constant assurances 
that he would get well. 

Ten days later, another laryngoscopic examination was 
made, with mild mechanical stimulation of the air passage. 
The patient remarked that he had never been so near being 
able to speak since his dumbness came on. The patient 
was now informed that his muscle of talking was going to be 
replaced and that the success of the operation depended upon 
his help, so that he was to shout out as soon as he became 
conscious of the physician's working inside his throat. The 
patient was given ether lightly, into the second stage. When 
consciousness was about to return, the laryngeal mirror was 
placed lightly on the larynx. The patient was commanded 
and encouraged to count out loud and shout. Speech re- 
turned permanently. 

It is to be noted that there was no specific war effect 
underlying the phenomena, unless we regard the fact of its 
being war time as contributory to the shock produced by an 
incident in every day engine room duties. 



J28 TREATMENT AND RESULTS 



Gradual onset of mutism and amnesia without 
special occasion. Faradism. Dream. 



Case 520. (Smyly, April, 1917.) 

A soldier was slightly wounded in the arm and returned 
to the trenches. Later he found himself in hospital at 
Boulogne, unable to speak and unable to remember what 
had happened to him from the time he was in the trenches. 
It appears that his voice and memory had gradually disap- 
peared, according to what was told him by his comrades. 

A month afterward, in a London hospital, the patient was 
roused suddenly from sleep, and then proved able to speak, 
although there was great difficulty in getting each word out. 
Two months later, he went to bed, feeling indisposed, in the 
night had a kind of fit, and remained unconscious until the 
following night; the next morning, his voice was again lost. 
The aphonia persisted for a fortnight, and the patient could 
hear only loud shouting when close to his ear. He was 
anxious to get well and requested electricity from the physi- 
cian, Dr. Smyly, having heard probably of another case 
cured thereby. Dr. Smyly applied faradic current to the 
larynx externally, instructing the patient to blow at the 
same time. At first the patient spoke so low that he could 
not hear himself speak, but on suggestion succeeded in 
speaking up loudly enough. He was shortly able to speak 
and hearing improved. The climax arrived with a bad 
dream one night, from which the patient awoke in a fright 
and found himself able to hear and speak perfectly. 

Re nocturnal spontaneous cures, see observations by Mott 
under Case 473. Note also in this case the presence of 
what Mott has termed " the atmosphere of cure." 

Re relapses, see Case 476 as well as remarks under Case 
474. Re special cases of mutism, Goldstein has insisted 
upon a greater individualization of treatment for func- 
tional mutes than even for other neurotics, and advocates 
the establishment of schools within the hospitals and after- 
care institutions. He thinks the problem very serious. 



TREATMENT AND RESULTS 729 



Shell-shock blindness : Cure by a course of injec- 
tions in the temple. 



Case 521. (Bruce, May, 1916.) 

A soldier from Gallipoli was admitted to the Royal Vic- 
toria Hospital at Edinburgh, blind. He had been at Gal- 
lipoli from May 1, 191 5, until August 12, when a shell explo- 
sion blew in his trench and buried him. He was dug out 
nervous and tremulous. Shortly afterwards there was the 
bright flash of a second shell, and amnesia set in until he 
found himself in hospital. He could not see at all with the 
left eye and the sight of the other was poor. He arrived in 
Scotland, October 9. He was nervous, excitable and now 
somewhat depressed, complaining of blindness and pain in 
the left eye, and headache. The left eyelid drooped. The 
fundus was normal. He had not been given an anesthetic. 

It was explained to him that the eye had not been injured; 
that it had become weak from the explosion; that he would 
be given a series of injections into the left temple of a strong 
drug which would restore the sight of the eye. 

Gradually increasing quantities of normal saline solution 
were given every morning. After four days he said that the 
treatment was doing him good. A week later he said that the 
eye was much stronger. After the fifteenth injection he could 
not sleep. The headache was worse, and there was "moving 
about inside his head." Early in the morning he went 
to sleep after a period of restlessness. He awoke at eight 
o'clock able to see perfectly, and was overjoyed at the result. 
There was some blurring and four days later he said he was 
becoming blind again. More normal saline was injected, 
causing pain. After that there was no relapse, and the man 
was sent back to his unit. 

Re Shell-shock blindness, Ormond and Hurst recom- 
mend a light hypnosis; taking the functionally blind man 
into a dark room and requesting him to make his mind a 
blank. Some cases are refractory. An anesthetic may be 
used with suggestion in the semi-conscious stage. 



73° TREATMENT AND RESULTS 



Deafness, cured by suggestion in writing. 



Case 522. (Buscaino and Coppola, 1916.) 

L. G., 20 years old; fusileer. (Mother of neuropathic con- 
stitution. Father died in 50th year of heart disease. One 
brother had hemiparesis from infantile cerebropathia.) The 
patient suffered from infantile otitis media bilateralis, which 
was followed by abundant chronic otorrhea from his fif- 
teenth year. He relates that for a long time he was obliged 
to wear a very large handkerchief on his shoulders to receive 
the pus, which came from an ear. No sex disease. Noth- 
ing of importance in the physical anamnesis. 

Patient entered the army, Jan. 15, 191 5. In May, he was 
sent to the front (Basso Isonzo). Towards the end of July, 
while he was in the trench, a grenade exploded a short dis- 
tance from him, causing slight abrasions at the nape of the 
neck and in the fleshy part of the left calf. He was picked 
up in an unconscious state, and taken to the hospital at 
Cervignano, where he was admitted as a deafmute and was 
given electric treatments. After 18 days or so, first stam- 
mering and then pronouncing with difficulty a few words, 
he finally regained his speech entirely. Deafness continued, 
however. 

Being transported to a special hospital in Florence, he 
was in a state of psychic excitement for several days, showing 
also visual hallucinations — saw "many soldiers," saw " many 
soldiers all about him." He was treated with chloral and 
bromide. The suspicions of several physicians were aroused 
by the obstinate declaration by the patient that he was in- 
curably deaf. 

On being admitted to the clinic on August 22, he showed 
complete deafness in addition to a slight degree of stupor; 
he remained impassive to the glance of his questioner without 
showing signs of worry about his condition, nor did he make 
any effort to make himself understood by making lip-move- 
ments (which is in contrast to another patient affected by 
organic deafness, who on the contrary made great efforts to 



TREATMENT AND RESULTS 731 

understand anything said to him, clearly showing his great 
grief over his incapacity). 

He failed to respond to auditory stimuli either by air 
or by bone conduction. It was possible from the begin- 
ning to exclude suspicion of simulation; during the day, 
indeed, it was not possible by any of the repeated attempts 
to awaken surprise in the patient by means of an acoustic 
stimulus. At night, while the patient slept, it was possible, 
however, to awaken him by calling his name, or by making 
a fairly loud sound; the patient would then open his eyes 
but was quite unable to hear. Neither confusion nor hallu- 
cinations were in evidence. 

He was able to converse very well and spontaneously (he 
remembers having lost consciousness at the explosion of the 
grenade and not coming to until after his arrival at the hos- 
pital at Cervignano) ; he read correctly both mentally and 
aloud, and answered by signs the questions put to him in 
writing. Being face to face with hysterical traumatic deaf- 
ness, notwithstanding no other hysterical phenomena were 
noticed, a successful attempt was made with suggestive 
therapy, the patient being emphatically assured (always in 
writing) that the following Sunday his hearing would be re- 
stored without doubt. The following Sunday, in fact, dur- 
ing the visit of a lady (one of his friends) , hearing in his left 
ear was suddenly and almost completely restored to the 
patient. He was in profound emotion on account of this, 
and upon the appearance of the physician he had a hard 
weeping spell. During the following day, he began slowly 
to hear with the right ear. 

During the latter part of his stay at the clinic, however 
(until September 24, 191 5), a slight hypo-acusia in the right 
ear persisted, along with severe headaches and pains in the 
left ear (which the patient compared to the suffering as a 
child with otitis). 

At the otoscopic examination by a specialist, only residuals 
of the old catarrhal otitis with retraction of the tympanic 
membrane were found. 



73 2 TREATMENT AND RESULTS 



Shell-shock story reproduced in hypnosis. Re- 
covery. 



Case 523. (Myers, January, 1916.) 

A private had been found wandering in a village, in shirt 
and socks, unable to give name, regiment, or number. He 
was admitted at a field ambulance, and seen by Major Myers 
three days later. No Christian name seemed familiar to 
him. The past was a blank. He was depressed. There was 
numbness over the occiput. The legs, hands and tongue 
were tremulous. The left arm and leg and the left side of the 
face, chest and abdomen were hypalgesic. The knee-jerks 
were exaggerated ; pseudo-clonus of left knee and right ankle. 
There had been a nightmare of bombs thrown into trenches — 
one thrown by a German hit him in the neck and woke him 
up in a cold sweat. 

In hypnosis the dream was repeated, and points about his 
previous life were dragged out piecemeal. Next, the names 
of village and near-by town, and finally his own name, regi- 
ment and number were elicited. After the bomb-throwing, 
he said, " I must have gone off my head and run away. I 
must have taken off my clothes in a field. I spent the first 
night under a hedge. I spent the next two nights in a wood. 
I ate nothing. The next night I was walking along a road 
on the outskirts of a village and I was taken to a house by 
two men." On waking, he proved unable to remember these 
things and was promptly rehypnotized, whereupon the 
memories became clearer and more ample. More powerful 
suggestion was given, and complete recovery of memory 
followed the second period of hypnotism. The pupils be- 
came larger. The despondency disappeared, together with 
the occipital numbness and the left-sided hypalgesia. He was 
transferred to a base hospital, and thence after three weeks 
to a hospital in England, made an uninterrupted recovery, 
and rejoined his regiment. 



TREATMENT AND RESULTS 733 



Shell-shock story reproduced in hypnosis. Re- 
covery. 



Case 524. (Myers, January, 1916.) 

Private, 29, seen by Major Myers in a base hospital the 
day after entrance, was in a stupor from which he had to be 
repeatedly roused to answer questions. He could recall 
neither name, regiment nor age, and was unable to write or 
read except a few letters in very large type. Twice he said 
the words war and comrade, and made a gesture as if follow- 
ing. He agreed that a shell came and intimated that he had 
pains in the forehead. He could not hold his hands out for 
many seconds without dropping them. Knee-jerks brisk. 

Four days later he was very little better, never having 
spoken voluntarily, but replying yes to the utterance of his 
name, and was able with great effort to write his name. He 
still intimated his severe headache. The next day the names 
of his two children were given. He could not read aloud the 
figure 2 but held up two fingers. Next day, he gave syllable 
by syllable his wife's name from her photograph. 

A week from admission he was hypnotized and persuaded 
to talk about the events that preceded his disorder, breathing 
excitedly, gesturing, and evidently visualizing the scenes. He 
had been in the trenches, had been sent to draw water at a 
camp, and had been knocked down when two or three shells 
burst over him. He carried out post-hypnotic suggestions. 

He was hypnotized again, two days later, and now de- 
scribed how, after shelling, he had lain on the ground, dazed; 
had risen, picked up the water bottle, returned to the trenches, 
and then lost all sense and reason. He recalled how his mates 
had told him he was silly, but had lost all intervening mem- 
ories. But the full details were elicited by persuasion. Next 
day he complained that he still wrote with difficulty. Under 
hypnosis, his speech and writing were restored to normal. 
He was discharged two days later to an English hospital. 

He was then passed for foreign service, being prevented 
from active service in the field by occasional severe headaches. 



734 TREATMENT AND RESULTS 



Burial after explosion of a " coal box " : Automatism, 
amnesia, deafmutism : Recovery by hypnosis. 



Case 525. (Myers, September, 1916.) 

A sergeant, 18, with nineteen months service in the army, 
11 months in France, was seen by Lt. Col. Myers at a clear- 
ing station to which he had been transferred after three days 
in another clearing station, with a note " Found in the streets 

of B , asking his way to the fire trench ; could not be 

got to speak on admission nor since; seems deaf, but now 
writes rationally." 

Mute and very deaf at the second C. C. S., he regained a 
good deal of his hearing with encouraging talk and also be- 
came able to cough and utter P, B, F and S, finally whispering 
name, regimental number, and the like. At the same time 
he could write fluently. After being buried he had lost 
himself until he had asked his way of a military policeman 

at the crossroads in B . There was amnesia again until 

he had been 48 hours in the clearing station at B . The 

throat hurt as if it were pulled down when he tried to speak, 
and his head ached when he tried to remember. There was 
much tremor, especially of right arm. In a quiet room ad- 
joining, the tremors increased and there was much agitation. 
Lt. Col. Myers suggested cure and encouraged the man, 
finally inducing a mild hypnotic state in which he spoke aloud, 
at first hesitatingly, later fluently. 

The man eventually remembered what had happened after 
he had extricated himself. He had run, as he thought, 
towards the fire trench, taken a wrong direction, and met a 
Frenchman who gave him eggs and bread, allowed him to 

sleep on a couch, put him on a cart and drove him to B . 

He was then very giddy and asked his way of the policeman. 
The shell by which he was "terribly shaken" was a "coal box." 
Posthypnotic suggestion that the headache would not recur 
and that he would shake hands with the orderly was success- 
ful. He now talked in a proper voice, at first hesitatingly. 
He looked another man as his clay-colored face resumed a 



TREATMENT AND RESULTS 735 

normal aspect. After a good night's sleep he was evacuated 
to a base hospital, thence to an English hospital, whence he 
wrote six days later in gratitude for the successful treatment, 
stating that he was now nearly well and hoped to be fit for 
light duty. 

Six weeks later he wrote that he was still dizzy. He also 
remembered certain further details of his experience ; how he 
had wandered into a listening sap in front of the Huns' 
barbed wire and had had a tussle with three Huns, after which 
he was buried during the heavy shelling. 

This case belongs in the group termed by Myers 
"A Group," namely, the physical group, in which the 
patient has been lifted, buried or knocked over by a 
shell or otherwise felt physical or chemical effects of an 
explosion (in contrast with the B Group, or psychical 
group, in which fear of the noise or emotional response 
to the mutilation of companions is the exciting cause). 
Predisposing affections occur as often in the physical 
group as in the psychical group. The average age of 
mutism cases seen by Lt. Col. Myers is twenty- five. 
Mutism is rare among commissioned officers. Lt. Col. 
Myers has heard of but one or two cases. 

With respect to the technique of getting these men to 
utter sounds, Lt. Col. Myers states that he first assures 
the patient that he has already cured many cases of 
loss of speech by the method about to be employed. 
The patient is next asked to copy his teacher as the 
sounds (not the vowels) B, D, finally V, S and K are 
made. The patient is, as a rule, shortly induced to 
make the necessary movements of lips, tongue or throat. 
" You see you are beginning to talk. Now let me hear 
you cough." The patient coughs. " You see you are 
able to make a noise. I want you next to cough out 
an A (Continental pronunciation)." After a time the 
patient adds this vowel to the cough. Other vowels 
are now taught him. Eventually a consonant is pre- 
fixed to the vowel instead of the cough. The patient is 
now delighted with his progress and can shortly repeat 
surname and regimental number. 



73^ TREATMENT AND RESULTS 



Mutism: Recovery by hypnosis. 



Case 526. (Hurst, 1917.) 

A transport driver, 31, was run over by a loaded wagon at 
Gallipoli in May, 1915, and fractured his pelvis. He re- 
mained perfectly conscious but unable to speak for three days. 
At the beginning of August, when he was admitted to the 
war hospital, he still spoke with great difficulty and with 
contortions of his face. Even when he did not speak, he had 
facial contortions and that mental condition characteristic of 
tic, namely: although he was able to control the contortions 
by will, he felt uncomfortable during the control and finally 
gave way to the irresistible impulse. 

Under hypnotism, it was suggested to him that he would 
be able to speak without difficulty and would no longer have 
the contractions of the face. When he came out of hypnosis 
he was able to talk quite normally, sang next evening at a 
concert, and a few days later he took part in a play. The 
facial contortions persisted in hypnosis and even afterwards, 
but vanished after a second hypnosis. 

Re hypnosis as treatment of mutism, Ballard remarks 
that a genuine return of speech and a merely hypnotic 
speech must be distinguished. 

Nonne is the great exponent of the use of hypnotism in 
treatment of the war hysterias. He got as good results 
from high as from lower classes of men. He remarks that 
the hypnosis does not protect against recurrence if the patient 
again falls under the original conditions that brought about 
the first attack. Hypnosis may be used also as a diagnostic 
measure between functional and organic cases. Even tics 
and tremors have been at times cured. 

Re employment of hypnotism, Hurst suggests that it may 
well be used, not only in mutism, but in hysterical deafness, 
blindness, and occasionally in psychasthenia. It is not a 
cure-all for the war hysterias, but is to be used as a not in- 
frequent form of treatment. Nonne claims cures of 51 out 
of 63 cases of hysteria major (28 rapidly, 23 more gradually). 
Ten of his 63 proved refractory to hypnosis altogether. 



TREATMENT AND RESULTS 737 



Stammering: Cured by hypnosis. 



Case 527. (Hurst, 191 7.) 

An Australian, 22, wrote the following, August 21, 1916: 
" You may be a little surprised to hear that I am in 
the Hos. suffering from shell-shock, which has taken 
away my speech and hearing. It is some sixteen days 
now since it happened. . . . We were in the trenches 
and going for dear life, when two of us spotted a Ger- 
man machine gunner in a hole, so we made up our 
minds to have him. We made a charge at him, and I 
just remember getting to him when a high-explosive 
shell burst at my head; it seemed as if it burst inside 
my head; everything went black. I tried to call out 
and couldn't, and I could not hear my mates — only 
just a terrible bursting in my head all the time. I 
never remembered anything more until I came to on the 
boat. The Drs. have told me that I will get alright in 
time. I saw a good deal of France. . . . There is not 
a young man there who is not in the Army. The girls 

and women work in the fie " 

The abrupt ending of the letter was due to the entrance of 
Major Hurst. The patient had been hypnotized but his 
deafness had persisted during the hypnotic sleep, so that sug- 
gestions could not be effectively taken. He heard nothing 
whatever during a very heavy thunderstorm, was unable to 
make any sign whatever, and could not even cough. 

He was now told in writing that his speech and hearing 
would be restored when ether was given. After a few whiffs, 
he struggled and before he was under began to repeat the 
word " Mother." Etherization was discontinued before his 
limbs had even become relaxed. As he was coming to, he 
was requested to repeat various words, and when the anes- 
thetic had passed, he was talking normally and had completely 
recovered hearing. 

Now, however, his memory had become a complete blank. 
From a short time before his shell-shock up to the moment of 
his regaining consciousness after etherization, he remembered 
nothing of his loss of speech or hearing, nothing about the 
events in his letter, and nothing about Major Hurst, whom he 



73§ TREATMENT AND RESULTS 

felt he had not previously seen. According to Hurst, this 
patient had become (a) speechless from fright at the time of 
the shell explosion, (b) deaf from the noise of the explosion, 
and (c) unconscious from the windage. After he came to at 
the time of the explosion, an autosuggestion to the effect 
that he had lost his power of speech and hearing occurred. 
Ether broke down this inhibition of speech and hearing by 
interfering with the control of the high over lower cerebral 
centers. 

Re emotional stammering, Chavigny treats by voice gym- 
nastics, rhythmical breathing movements, sounds spoken by 
metronome with simultaneous movements of arms or trunk, 
and by singing. Re hysterical stuttering, Roussy and Lher- 
mitte remark that the symptoms are always very pro- 
nounced, come on suddenly, and cease just as suddenly under 
the influence of electrical treatment. The history will dif- 
ferentiate hysterical stuttering. The effects of treatment 
will also help. Genuine non-hysterical stammering may, of 
course, be increased through emotion or shock. Dundas 
Grant aids the stutterer by having him twist a button or 
carry out some other muscular movement simultaneously 
with the attempt to speak. He also has the patient endeavor 
to expand the lower part of his chest during the effort. 

MacMahon notes that Shell-shock stammering is chiefly 
a difficulty with vowel sounds and voiced consonants, and 
amounts to a speech inhibition, accompanied sometimes by 
amnesia for words and suggesting a form of aphasia. Mild 
cases of such stammering are cured simultaneously. Mac- 
Mahon relies in part upon especially regulated breathing 
movements and the attendant sense of repose. The cases of 
old cured stammering that have come back under Shell- 
shock are harder to treat. 



TREATMENT AND RESULTS 739 



Two burials; shell-shock: Mutism and amnesia. 
Recovery aided by hypnosis. 



Case 528. (Myers, January, 1916.) 

Major C. S. Myers recites hypnotic cure in a case of mutism. 
He remarks that malingering is sometimes suspected in these 
cases. There was, however, in this case a severe constipation 
which lasted five days from the shock, and a retention of 
urine with catheterization during the same period. This 
private, 32 years, came to a base hospital, mute but able to 
read and write as follows: 

" I was buried alive on and again on [5 

months and 4! months respectively before admission], 
and then I had the misfortune to have two shells burst 

over me on [four days before admission]. There 

was shelling for about 20 minutes and then two bursted 
over my head. I did not remember any more until 
you came to see me, but I am still living in hopes to 
regain my speech back." 
It seems that he had wandered off with a lance-corporal for 
three days after the first burial, and neither he nor his com- 
rade were able to find their regiment. 

Understanding was slow and look vacant. There were 
jerky movements of the arms and a snoring sound from the 
nasopharynx. Voluntary movements were restricted, weak, 
slowly executed, jerky, and incoordinated, but not tremulous. 
Station was unsteady; failure in finger-to-nose test. He 
could imitate the sound ah, and the consonants s and p. 

Knee-jerks exaggerated; plantars flexor; abdominal re- 
flexes absent; pupils reacted; eye movements normal; 
moderate restriction of visual fields on temporal side; watch 
not heard even in contact with ear ; heard better by air than 
by bone conduction. 

In the next two days, the patient became brighter and 
movements became better. On the seventh day stupor and 
ataxia had disappeared. Familiar names could be repeated 
and the next day could be given on request. The patient 
would sweat profusely in giving replies. There was no spon- 
taneous speech. A week later speech had improved. 



740 TREATMENT AND RESULTS 

Under hypnosis he spoke more fluently though feebly, and 
became emotional upon being questioned as to trench life, 
waking up suddenly from hypnosis and wiping the sweat 
from his chest. 

The next day, forgotten events of the second burial were 
recalled together with what followed. Post-hypnotic sugges- 
tion of the performance of eccentric actions was successful. 

Next day his memory had returned save in reference to the 
two days' wandering after the first burial; and under hyp- 
nosis the events of those two days were recalled. He was 
then transferred to an English hospital. 

Re hypnosis for "war shock," Eder remarks that the usual 
objections to hypnosis cannot apply because the majority of 
cases have no neuropathic antecedents. Eder, as psycho- 
analyst, endeavors to level hypnotic suggestion against the 
so-called " complexes." Elliot Smith and Pear commend 
Lt.-Col. Myers' results, but regard the results of hypnotic 
treatment as brilliant but erratic. Colin Russel, regarding 
hypnotism as an induced hysteria, remarks that a true 
hysteria can hardly be cured by adding more, although he 
has sometimes used the treatment with apparent success. 
Podiapolsky notes that some 17 per cent of his functional 
cases will, at a word, drop off into an artificial deep slumber. 
He thinks chloroform should not be given to these subjects 
without an attempt to secure this artificial deep slumber 
first. Chavigny, highly commending suggestion, notes that 
the use of hypnotism is prohibited in military hospitals in 
France. A remark of Smirnow indicates that the Russian 
authorities also look with disfavor upon hypnosis, but he 
notes certain patients whom he cured by hypnosis, so that 
apparently Russia did not absolutely forbid the use of hyp- 
nosis in war cases. Another Russian, Arinstein, prefers the 
Dubois method to hypnosis. 

Roussy and Lhermitte definitely state that the psycho- 
therapy of Dejerine, Dubois, and Babinski beneficially re- 
places hypnotic suggestion, " which ought definitely to be 
rejected." However, if the conclusions of Bernheim are 
sound, there can be no theoretical claim of distinction be- 
tween hypnosis and other forms of suggestion. 



TREATMENT AND RESULTS 74 1 



Fifteen bayonet wounds ; recommendation for Vic- 
toria Cross: Hysterical contracture of hand, re- 
vealed by hypnosis as the bayonet clutch. 



Case 529. (Eder, August, 191 6.) 

A left-handed Irishman, 23, on December 22, 191 5, got 
15 bayonet wounds, 14 of which were on the right side of the 
body. He was in the trenches with 23 men, when they were 
attacked by about 200 Turks. He and a sergeant leaped out 
of the trench into a bayonet attack with Turks. 

He was admitted to the hospital January 26, 1916, for a 
hysterical contracture of the right hand. The fingers were 
semi-flexed and could not be passively extended. Col. Purves 
Stewart noted that there was an anesthesia and analgesia to 
pin-pricks and cotton wool on the whole of the right arm. 
" At the beginning of the examination, the patient felt pin- 
pricks at the wrist; as examination continued, the boundary 
of anesthesia steadily increased until it reached the shoulder, 
by which time the previously sensitive spots were now anes- 
thetic." Later there was a complete right hemianesthesia. 

In telling his story, this soldier repeatedly emphasized that 
11 You must clutch your rifle very firmly and never let it up, 
guarding yourself all the time." This was the explanation 
of the contracture. According to Eder, in the unconscious, 
he was still clutching the rifle, fighting the good fight, and 
symbolizing the desire by the grasping hand. In hypnosis, 
suggestion was made that the fight was over and the rifle 
could be let go, whereupon the hand was immediately relaxed. 

The analgesia, thinks Eder, was present during the fight 
and passed away subsequently. In fact, the soldier said that 
he felt no pain during the fight and did not know that he was 
wounded until his attention was called to the fact that blood 
was flowing from him. According to Eder, the unconscious 
mind refused to feel pain. At Col. Stewart's first prick or 
two " the unconscious took no notice, but as the pricks con- 
tinued, the former memory was revived and the unconscious 
became on guard." He had been recommended for the V. C. 



742 TREATMENT AND RESULTS 



Gunshot of forearm: Hysterical contracture, wrist 
and fingers : Cure by hypnosis, " indecently quick." 



Case 530. (Nonne, December, 1915.) 

An infantryman, without special hereditary taint and pre- 
viously well, was shot September, 19 14, in the right forearm. 
A paralysis of the hand and fingers persisted after the wound 
had healed. Several reserve hospitals failed to cure the 
paralysis. 

Eight months after the injury he arrived at Nonne's clinic 
at Eppendorf, with a flexor contracture of the right wrist 
joint as well as of the fingers (exclusive of thumb). The 
finger tips were deeply sunk in the flesh of the palm. Ex- 
tension could only be brought about against strong resistance. 
There was a total anesthesia for all sensations in the hand and 
fingers. No contraction of visual fields. 

The patient, upon suggestion, fell immediately into hyp- 
nosis. At first the contracture was released with some diffi- 
culty; then, with greater ease, and then without any 
resistance whatever. During the same hypnotic seance the 
patient finally became able to extend actively both fingers 
and wrist; and next day, after the patient had convinced 
himself of his cure, he was able voluntarily to stretch the hand 
and fingers with normal amplitude and power. The disturb- 
ance of sensibility had spontaneously disappeared. 

This cure was, from the patient's point of view, indecently 
quick. He said everybody must feel he was a malingerer, and 
in fact he felt so himself. He went back into service, where 
he had been for several months at the date of Nonne's report. 

Re Nonne's enthusiasm for hypnosis, see under Case 526. 
Nonne, contrary to Babinski and Froment, would regard 
even the severe and obstinate vasomotor disturbances as 
purely functional and as not even "sub-organic." The basis 
of this belief is that hypnosis cures these phenomena as well 
as various tics and pertinacious tremors. French observers 
consider that these tics and tremors may even be organic 
in their nature, basing their ideas upon the non-success of 



TREATMENT AND RESULTS 743 

suggestion. (It may be noted [see under Case 528] that 
the French military authorities do not allow the use of 
hypnotism in the army.) With respect to the present case 
(53o) > of course, the French observers would not deny the 
power of hypnotism to produce the cure. Babinski and 
Froment's Postscript to the English edition of their work on 
hysteria, remarks that, though Roussy and Lhermitte state 
that vasomotor symptoms may disappear along with the 
psychotherapeutic cure of paralyses and contractures, yet 
Roussy and Boisseau later admitted that improvement in 
thermal and vasomotor control is at best an exceedingly 
slow one. 

More recent personal communications indicate that there 
is still room for some question as to the curability by sugges- 
tion of such disorders as tic, tremor, vasomotor imbalance, 
and the like. In short, the true scope of the " pithiatic" 
or suggestion-curable diseases is still somewhat a matter of 
controversy. 



744 TREATMENT AND RESULTS 



Shell-shock: "Doll's head" anesthesia, mutism 
Hypnosis. 



Case 531. (Nonne, December, 1915.) 

An officer, mute for five months following shell-shock, had 
been for four months treated in a succession of hospitals — 
field hospital, war hospital, two reserve hospitals. 

He had no acquired or hereditary neuropathic taint, but 
even in the period before the critical shock he had been under 
tremendous physical and mental strain. The explosion 
produced a total anesthesia of the skin of the head, face, 
neck and shoulder region — in short, what Charcot called 
the " doll's head " form of sensory disorder. Moreover, 
there was a marked contraction of the visual fields. 

The patient, when treatment was given, fell at once into a 
deep hypnosis and began to intone, and then to speak iso- 
lated words, and finally to speak complete sentences. All 
that was left of his mutism was a slight over-fatiguability of 
the speech organs. This also cleared up in the next few days. 
He was discharged well, and had already been — December, 
1 915 — some months in the field. 

Case 531, though an officer, responded to hypnosis well, 
and Nonne remarks that hypnotizability is independent of 
the presence of any neuropathic tendencies, or of any loss 
of resistance through exhaustion. One trouble with the hyp- 
notic method, according to Nonne, is the fatigue of the 
hypnotizer and his inability to rely upon assistants. 

Re Charcot, Nonne remarks that the work of Charcot on 
hysteria is not sufficiently well-known, especially as civilian 
practitioners in peace times had few cases. Re taint, Nonne 
found such tendencies absent in more than half of his cases 
with careful anamneses. The absence of adequate psycho- 
genic cause is a not uncommon experience according to 
Nonne. Nonne, finding 26 cases of pure neurosis amongst 
1800 cases of war injury, had a considerable number of odd 
erroneous diagnoses in the group. Not only were cerebro- 
spinal paralyses wrongly diagnosticated, but ischemic paraly- 
sis, plexus paralysis, arthritis deformans and synovitis. 



TREATMENT AND RESULTS 745 



A soldier is put in the Landsturm at 22 and later 
called "unfit" by reason of tremors after mine- 
explosion (history of tremors at 14 after a fall), but 
is cured by hypnosis. 



Case 532. (Grunbaum, November, 191 6.) 

A Landsturm soldier, 22 (father excitable, family other- 
wise normal), had a history of being the best scholar in the 
class and well up to his fourteenth year. At 16 he fell from 
a tree and though he apparently sustained no injury his head 
and arm began to tremble. He became unable to learn and 
gave up his preparations to be a teacher. The tremor, 
however, disappeared in six months and he went into some 
technical work. At 16J years he went as cabin-boy, but in 
a fortnight he was sent home by the physician. He then 
began to breed carrier pigeons and got first prizes at inter- 
national exhibitions. He also went into foundry work and 
did well as an apprentice. He worked well at home and 
busied himself with setting up small electrical and other ma- 
chines. He had never been interested in women and loved 
his pigeons best, and therefore was regarded by people who 
knew him as not quite right. He was also non-alcoholic. 

After mobilization he was sent back twice but finally was 
put into a Jager Battalion. After reaching the front he had 
to have a hernia operation and on getting well went back to 
his place and a few days later a mine exploded near him. He 
was much frightened and fell down unconscious. On re- 
gaining consciousness he felt a " running " in the legs and 
tremors in the hands. The latter grew stronger and began 
to affect the arms. 

After two months in hospital he went to garrison unre- 
covered, was placed in the Landsturm and did four months 
station duty in Russia. The tremors persisted and when his 
comrades played a bad practical joke on him the tremors got 
so bad that he was sent back home as unfit for service. 

He was a stocky looking, well-nourished man of middle 
height, without visceral disease or sign of organic nervous dis- 



746 TREATMENT AND RESULTS 

order. The shaking tremor grew much more powerful in 
any state of excitement but always paused sufficiently to 
permit the execution of any particular movement. The head 
movements were continuous, slight rotations. There were a 
few regions of anesthesia to touch, but these areas differed at 
different examinations. There was a general hyperesthesia. 
Conjunctival, corneal and pharyngeal reflexes were absent. 
The man was slightly excitable, apprehensive, depressed, 
complained of sleeping badly, did not want to sit or stand and 
felt as if he wanted to run away, no matter where. In drop- 
ping off to sleep he would fall out of bed and talked aloud in 
his sleep. He thought he was incurably sick. Intelligence 
and school knowledge were very good. 

He was hypnotized eight times for periods of about five 
minutes each. Hypnosis was extremely easy to accomplish. 
At the second trial the manual tremor disappeared. After 
the third trial there was an essential improvement in the 
shaking tremor. Moreover, his emotional state had become 
happier. He began to sleep well. He was now free from 
disease and regained confidence and looked upon himself 
as well and fit for work. Undoubtedly without hypnotism 
this man would have been released from service after a few 
months of inconsequential hospital care without pension. 

Re tremors, see remarks under Case 308, concerning the 
possibly organic nature of many of the so-called Shell-shock 
tremors; an opinion apparently shared in by Meige and by 
Guillain. Babinski also found that these tremors were not 
influencible by psychotherapy. Yet here is an instance in 
which tremors are reported cured by hypnosis, and more- 
over, tremors that were recurrent from an ante-bellum at- 
tack at 14. See remarks under Case 530, 



TREATMENT AND RESULTS 747 



Shell-shock, slight injury, unconsciousness: As- 
tasia-abasia : Recovery under hypnosis, two seances. 



Case 533. (Nonne, December, 191 5.) 

A musketeer, without neuropathic taint and without ner- 
vous symptoms before the war (parents both dead of tuber- 
culosis, eleven brothers and sisters died young), saw four 
comrades killed by a shell October 27, 1914. The musketeer 
himself was slightly injured superficially in the back. He 
remained unconscious for three hours and on coming out 
showed general tremor of the body, felt pressure in the head, 
was lachrymose and unable to walk or stand. He was sub- 
ject to insomnia. He was in four different hospitals, finally 
reaching Eppendorf. Diagnosis rendered at the first hospital 
and carried on through the others was hemorrhage into the 
spinal canal. 

For two months at Eppendorf he lay in extension. He 
was then examined by Nonne, who found general neuro- 
pathic habitus, pronounced " cramp neurosis " in the lower 
extremities, psychogenic astasia-abasia, hyperidrosis of the 
lower extremities, marked cyanosis of feet and lower legs, 
increased tendon and skin reflexes, pseudoclonus, no Babinski 
or Oppenheim reflexes. The man complained of pressure 
in the head, sleeplessness, a feeling of depression and hope- 
lessness. Pulse 120-130. 

Hypnosis proved easy. After the first treatment the man 
stood and walked and showed no tremor. The next day the 
hypnosis was repeated and the cyanosis of the legs dis- 
appeared. Sleep on the second night was good. Appetite 
returned and the man fell into a good emotional state. 
Thereafter the patient was intentionally ignored by the 
physicians and could soon not be distinguished in any re- 
spect from the other non-nervous convalescents. 

This case is expressly stated by Nonne to resemble in all 
respects those formerly described by Oppenheim as " trau- 
matic neurosis." 



748 TREATMENT AND RESULTS 



Crural monoplegia: Cured by hypnosis. 



Case 534. (Hurst, 1917.) 

A Belgian soldier fell into mud on the collapse of a roof 
from which he was observing the enemy. It was an hour 
before he got his left leg out of the mud, and found it fixed 
in extension. He was sent to England, where for three 
months the leg remained stiff. The spastic paralysis did not 
seem organic as the leg was dragged behind. The knee and 
ankle could be bent only by using much force. The entire 
leg was in all ways anesthetic. Babinski sign gave additional 
proof that the condition was hysterical : when the patient lay 
with arms folded and legs apart and then tried to sit up, the 
normal leg was lifted and the paralyzed leg remained flat. 

According to Hurst, the paralysis and stiffness were due 
to an autosuggestion from the legs being embedded in mud. 
The anesthesia was probably a matter of medical suggestion 
produced in the course of examination during the three 
months of disability. According to Hurst, Babinski is right 
in supposing that hysterical anesthesia is almost invariably 
produced by the observer. 

Accordingly a strong faradic current was passed through 
the leg, and he was assured that sensation and power would 
be restored. However, he could still walk only with diffi- 
culty. 

Hypnosis was therefore resorted to and repeated on several 
occasions. He went back to duty in three weeks, although he 
still held the leg somewhat stiff when he walked. 

Re recurrences after hypnotism, see remarks of Nonne 
under Case 530. Howland also notes that cases treated by 
hypnotism must be followed up to prevent relapse. In the 
above case of Hurst's, it will be noted that the hypnotic 
treatment was several times repeated. 



TREATMENT AND RESULTS 749 



Shell-shock, emotional (slight trauma) : Tremors 
and sensory impairment : Cure by hypnosis, thrice 
repeated. 



Case 535. (Nonne, December, 1915O 

A reservist, always well, not neuropathic (mother had had 
seizures, possibly epileptic, for many years) was wounded in 
the left calf by a shell fragment, about the middle of Decem- 
ber, 1 9 14. He was at the same time, as a result of the shell 
explosions near by, afflicted with a tremor of the whole body ; 
this tremor gradually increased and proved refactory to all 
treatment for nine months. 

At the beginning of September, 191 5, the patient reached 
Nonne's wards, showing tremor of head, arms and legs, 
with pronounced hypalgesia of the whole body, abolition of 
frontal and conjunctival reflexes, and contraction of the 
visual fields. 

The tremor of the head was completely removed at the 
first hypnotic treatment. There was a slight recurrence of 
this tremor two days later, and traces of it could be observed 
for nine days. A third hypnotic treatment swept away this 
tremor, which did not return. 

The patient was discharged after about four weeks, suit- 
able for garrison duty. 

Re traumatic neurosis, Nonne dislikes this term of Oppen- 
heim, because such a term rather tends to connote unfavor- 
able prognosis. As quoted under Case 530, Nonne holds 
that the war data show that hysteria is neither a form of 
degeneration nor an affair built on the Freudian schema. 

Nonne in fact maintains that the hysterical syndrome may 
occasionally occur with much greater ease in a normal per- 
son than ever has been known before. It is precisely in these 
cases of normals getting hysterical that Nonne gets espe- 
cially good results with hypnosis. If the development of 
the hysterical syndrome had extended over days or weeks, 
then the hypnotic cure was a slower one. The above re- 
servist developed his Shell-shock gradually and required three 



750 TREATMENT AND RESULTS 

hypnotic treatments. But although the number of doses of 
hypnotism required may be said roughly to depend upon 
the time which the condition took to come to a head, yet 
there is no similar rule re duration. A miracle cure may be 
brought about even in cases that have lasted over a year. 
This result, if confirmed, would signify that the hysterical 
condition once fixated did not especially increase in its 
tenacity. 

Re hypnosis in Germany, it should be noted that Nonne 
is the chief protagonist for hypnosis, at least among the 
well-known neurologists. Psychoelectric cures, which the 
Germans term Kaufmann's cure, are also greatly in vogue in 
German clinics. Despite the well-based claims of Lt.-Col. 
Myers and of Eder, some English observers appear to con- 
demn hypnosis as inadequate, or even as dangerous. 

A series of relatively successful cases like those here men- 
tioned might yield a wrong impression of the value of hyp- 
nosis (see Feiling's unsuccessful case 369). 



TREATMENT AND RESULTS 75 1 



Hysterical paraplegia of gradual development : re- 
covery only under repeated hypnosis. 



Case 536. (Nonne, December, 1915.) 

A volunteer, of nervous parents, had for four years suf- 
fered from attacks of uncertain (hysterical or epileptic) nature. 
These attacks came on again after strenuous marching 
in the campaign in Belgium and France. Released from 
service at the front and detailed for guide duty, he proved 
unsuitable for this work, too, and was sent back to a hospital 
at home. Here there gradually developed a paralysis of the 
lower extremities. Treatment proved ineffective. 

At the end of January, 191 5, he came to Nonne's wards 
at Eppendorf with a paralysis that had lasted six months. 
There was a total paraplegia inferior, with anesthesia for all 
sensation from the knees downward. The lower legs and 
feet were cyanotic and cold. The tendon and skin reflexes 
were lively. There was a moderate contraction of the visual 
fields on both sides. 

Under hypnosis, the patient proved able to move both 
joints somewhat, but very weakly and slowly. The patient 
was hypnotized daily for a week, and made slow progress. 
Only after another week did it prove possible to get him to 
stand. After four weeks, his gait had so improved as to look 
like that of a tired old man. Three weeks more of treat- 
ment permitted the patient to walk, run and hop normally. 
Repeated waking suggestion had failed to accomplish anything 
in this case. The improvement followed only hypnosis. It 
seems to be a general principle that in cases of gradual de- 
velopment, the recovery by hypnosis will also be gradual. 

Re repeated hypnosis for cases of gradual development, 
see remarks under the preceding case (535). 



752 TREATMENT AND RESULTS 



Struck by rifle butt: blindness of an eye already 
poor. Shell-shock: dysbasia. Hypnosis. 



Case 537. (Ormond, May, 1915.) 

A lieutenant, 20 years, managed to get into the army 
despite the fact that he had never been able to use his left 
eye, owing to hypermetropia and amblyopia. He was hit on 
the left side of the head by a rifle butt, and knocked uncon- 
scious, in June. On recovering, he found he could not see at 
all with his left eye, which he had never been in the habit of 
using. August 10, he was wounded slightly in the left thigh. 
August 23, while still on duty, with the wound not com- 
pletely healed, he was blown up by a shell. He regained 
consciousness on a stretcher. Feeling the pain in his old 
wound, he thought he should be unable to walk. 

On shipboard, he found that he actually could not walk. 
He kept his left eye covered by a shade on account of head- 
ache that would follow exposure to light. He was much 
excited and had bad nightmares. 

After the journey home from the Dardanelles, it was found 
that the left eye was normal except for the hypermetropia, 
despite the fact that he was quite unable to see with the eye. 

He was hypnotized four times, losing the nightmares and 
much of the headache after the first treatment; the eye pain 
on exposure to light, after the second treatment; and the 
blindness, after the third treatment. He was now able to 
see with his left eye as well as before he was struck. He was 
still unable to walk without crutches. Hypnotized the fourth 
time, he was told he could walk, and did so. 

For hypnotic treatment of blindness, see under Case 521. 
Re blindness of eye already poor, see Cases 294-301 (296 and 
297 eye cases). Ormond states that in the treatment of 
Shell-shock blindness, he first tried rest, tonics, cutting off 
tobacco, confinement in bed, isolation, persuasion, encourage- 
ment, counter-irritation; but that all these measures failed. 
Suggestion and hypnosis succeeded. 



TREATMENT AND RESULTS 753 



Shell explosion; concussion; retinal hemorrhage 
Blindness. Cure by hypnosis. 



Case 538. (Hurst, November, 1916.) 

An English private, 22, was looking over a parapet, July 
18, 191 5. He afterward remembered sand thrown in his 
eyes "and a fall backward, hitting his head, after a shell had 
struck the sandbags in front of him. He was unconscious 
24 hours. Upon recovery, he found himself completely blind, 
save that he could just tell light from darkness with the left 
eye. His eyes were sore and eyelids blackened; there was 
also severe headache and partial deafness. 

Hearing returned and the headache improved shortly ; but 
the condition of the eye seemed more permanent. On 
forcibly opening the eyes, September 14, they were turned 
far upwards so that the iris could scarcely be seen. Some 
sand grains were buried in the conjunctiva, not in the cor- 
nea. There was no inflammation about the sand grains. 

In hypnosis, he was told that he would see on waking. 
The moment he woke, this suggestion was repeated forcibly 
and his eyes were held open. He cried out that he could see; 
tears ran down his cheeks; he fell on his knees in gratitude. 
Three days later, he said he was able to see as well as he had 
ever seen. There was, however, an opacity of the vitreous 
of the left eye, the result of a retinal hemorrhage: doubtless 
the result of injury at the time of the explosion. September 
30, he had perfect vision in the right eye and 6/36 in his left. 

Re results of hypnotic treatment, Lt.-Col. Myers, sum- 
marizing 23 cases of Shell-shock, got apparently complete 
cures in 26 per cent, and distinct improvement in another 
26 per cent. He failed to hypnotize 35 per cent, and got 
no improvement after hypnosis in 13 per cent. Is the re- 
covery after hypnosis complete and permanent? Lt.-Col. 
Myers believes that it may be, but 'others remark the tend- 
ency to relapse (see Case 534). Similar objections may 
be made to the psychoelectric treatment as used by Vincent, 
Yealland, or Kaufmann. See under Case 535. 



754 TREATMENT AND RESULTS 



Appendix operation: Post-operative retention of 
urine. Relief by hypnosis. 



Case 539. (Podiapolsky, August, 1917.) 

A soldier, 32, operated for appendicitis, had a post-opera- 
tive retention of urine. Hypnotic suggestion was requested 
to reestablish excretion of urine before resort should be had 
to the catheter. 

Somnambulistic amnesia was obtained at once and with- 
out questioning him P. suggested to him directly that he 
must feel the need of micturition. The suggestion was un- 
successful. However, bearing in mind psychogenic obstacles 
of an unknown nature, P. questioned the patient as to sensa- 
tions and learned that in the operation the skin had been 
burned about the urinary passage and that the patient 
feared micturition. Besides this, micturition was painful on 
account of the wound above the appendix. The patient also 
feared that the sutures would yield. 

Accordingly assurance was given that the burned parts 
would be insensible and that the bladder could be emptied 
without effort and without endangering the sutures. Anal- 
gesia was produced by a few passages of the hand upon the 
bed clothes. Complying with post-hypnotic suggestion the 
patient urinated after a quarter of an] hour of sleep, and in 
thirty-six hours retention was relieved. 

With respect to frequency of immediate somnambulism for 
the first trial, P. states that, although authorities set the 
percentage of successful immediate somnambulisms at 17-20 
per cent, war conditions yield three or four times as high a 
percentage. The war has produced a suitable soil for hyp- 
notism. Hypnosis is impossible in from 1^ to 2 per cent of 
cases. 



TREATMENT AND RESULTS 755 



Wound of sciatic nerve: Pains after operation. 
Relief by hypnosis. 



Case 540. (Podiapolsky, August, 191 7.) 

A German prisoner, 33, was admitted to a Russian Hos- 
pital, November 11, 191 6, with "a bad wound of upper right 
thigh, marked pains in right sciatic nerve especially affect- 
ing feet." Morphine and pantopon did not abolish the pain. 
Insomnia. November 13, the sciatic nerve was surgically 
freed from a scar and laid in the midst of the femoral biceps. 
Every evening pantopon was injected; but the pains and 
insomnia persisted nevertheless. 

November 19, he was hypnotized. The pain stopped. 
He had an excellent night, and the next day felt only a slight 
pain in the toes. 

Curiously enough, while giving him suggestion in the Ger- 
man language, P. had said fingers instead of toes (inadvert- 
ently, since the Russian language uses the same term for 
both). He slept well to November 29 but still felt a slight 
pain in the toes. On November 29 another hypnotic sitting 
was given, and the toes this time were named correctly. 
The next day the patient said, "You have relieved me of all 
the rest of my pain." He had no pain thereafter and the 
morphine and pantopon were dispensed with. Sleep re- 
turned. 

Incidentally, this patient had his hair grow white in a few 
months of war. 



756 TREATMENT AND RESULTS 



Ship blown up by mine: Stereotyped explosion 
dream by survivor: Cure by hypnosis (also of 
antebellum habitual headache). 



Case 541. (Riggall, April, 1917.) 

A survivor of H.M.S. T.B. 11, blown up by a mine off 
Harwich, was admitted to the naval hospital at Chatham, 
March 3, 191 6, a well-nourished, nervous looking lad, aged 
20. After the accident, he began to dream, always the same 
dream, of the explosion, waking up with the cry of the ship 
mates, and then unable to sleep the rest of the night. The 
knee and ankle- jerks were somewhat exaggerated. 

April 15, when there had been no improvement, he was 
hypnotized. The patient was told to lie back in an arm 
chair, make himself comfortable and allow muscles to relax. 
He was told to fix his eyes and concentrate his attention on 
an electric lamp. The suggestion of sleep was made, and he 
was repeatedly told in a monotonous voice that he was be- 
coming more and more sleepy. Then in an emphatic voice 
he was told that the treatment would completely cure him. 
He had no more dreams after this first sitting. 

Hypnosis was continued every other day until April 20, 
when he was discharged cured. After the first sitting hyp- 
nosis was induced by simply telling the patient to go to sleep, 
which he would immediately do on entering the room, while 
still standing up. At subsequent sittings, he was made to 
write twenty times such phrases as: "I feel much better"; 
" Ifshall have no more bad dreams." 

Once when a tooth was to be pulled a post-hypnotic sug- 
gestion that no more pain would be felt was given, nor was any 
pain" felt. Headache persisted after the first two or three 
sittings. Accordingly, during hypnosis a| pencil was* pressed 
to the forehead with the suggestion that it would burn and 
that after waking there would be an itching pain for half 
an hour, followed by recovery from headache. Curiously 
enough, a distinct erythema of the skin was observed over 
the point of pressure. Toothache and headache vanished. 



TREATMENT AND RESULTS 757 



Shell-shock from air-craft bomb: Amnesia: Re- 
covery under hypnosis (also removal of a headache 
dating from childhood). 



Case 542. (Burmiston, January, 1917.) 

May 22, 19 16, a stoker, 26, was found on shipboard in a 
workshop behind oil drums, refusing to come out, looking 
dazed, not recognizing messmates, suspicious and complain- 
ing of headache. He reached the Royal Naval Hospital at 
St. Malo, May 24, answering questions " Don't know," and 
physically normal except for diminished knee-jerks. At the 
end of two or three weeks he would answer questions about 
his stay at the hospital, but complained of headache or 
weight in the head. Wassermann reaction, negative. 

Special examination on May 26, showed an amnesia for 
everything up to his arrival at St. Malo. For example, he 
did not know the name or use of a hammer or a pressure 
gauge, though he knew the pressure gauge was made of brass 
and glass, having seen brass and glass in the hospital wards. 
He had no idea of the nature of a ship. He was sent to the 
sick bay at the Royal Naval Barracks at Chatham, July 7, 
carrying a recommendation that he be retrained as a stoker. 

He was put under hypnosis, induced by gazing at the brass 
knob of a paper weight. He went off easily, was told there 
was nothing to worry about, taken back to the beginning 
of his illness, and asked what happened. He told about 
a bomb explosion from aircraft, and how he had lost his 
memory after a nearby explosion. He told how he was 
married and had a child 21 months old. During the nar- 
rative about bombs falling, his worry was such that he was 
put in a deeper hypnotic sleep, and was told that he would 
remember all that had happened. Upon being ordered to 
wake up, he remained dazed for a few moments, and then 
said that he was all right. Asked about his marriage, he 
replied that of course he was married and had a child. 

After four days leave, he returned, July 13, without trouble 
except a headache, from which it appeared that he had suf- 



758 TREATMENT AND RESULTS 

fered ever since a fall when a child. He was again put into 
a hypnotic state and asked to remember the accident that 
caused the headache. He was conducted back through the 
years, and finally described a white house in India, his fall in 
the area, the black people in white clothes, the cut bleeding 
head. He was told that he would have no more of such 
headaches. On being wakened, he said that his headache 
was gone, and retold the story of the accident. August 2, 
he said he had never felt better in his life. September I, he 
was drafted to a seagoing ship. 






TREATMENT AND RESULTS 759 



Shell-shock, unconsciousness: Convulsions (recol- 
lection of childhood convulsions) : Cure by hyp- 
nosis. 



Case 543. (Hurst, March, 1917 ) 

A New Zealander was rendered unconscious for a few 
minutes following concussion from a high explosive shell. 
Convulsions developed, occurring at least once and often 
several times a day. 

As to the origin of these convulsions, it appeared that the 
soldier had had a few convulsions after falling on his head at 
the age of 8. According to Hurst, recollection of these 
childhood convulsions probably led by a process of autosug- 
gestion to the Shell-shock convulsions. 

Captain Crab tree hypnotized the man, suggesting recov- 
ery. The fits immediately ceased and did not recur. 



Recurrent hysterical mutism. Spontaneous recov- 
ery in (a) 18 months (antebellum incident), (b) 
Hypnotic recovery in a few minutes. 



Case 544. (Eder, August, 1916.) 

A soldier in a mine accident eight years before the war, 
lost his speech when his brother was killed, and then re- 
covered his speech spontaneously after 18 months. 

After a shell explosion in Gallipoli, he was again struck 
speechless and also deaf. 

Six weeks later, he came to Dr. Eder and objected in writing 
to treatment, saying that he believed in nature's methods. 
God had taken his voice away before and had restored it. 
Eder replied in writing " rather irreverently " that God had 
taken 18 months, but he could do it in a few minutes. The 
patient afterward consented to treatment, and speech and 
hearing were duly restored in the time promised, whereupon 
Dr. Eder told him that in point of fact his physician was 
merely the instrument of Providence. 



760 TREATMENT AND RESULTS 



Neurasthenic symptoms: Cured by repeated hyp- 
nosis. 



Case 545. (Tombleson, September, 191 7.) 

A private, 24, was admitted to hospital with diagnosis 
neurasthenia, March 11, 1916. He suffered from vertical 
headache; general analgesia, more definite on the right side 
(patient left-handed); loss of smell and taste, also more 
definite on the right side; paresis of right leg, with dragging of 
foot (old trench foot) ; and sleeplessness. 

The next day Tombleson put him in a hypnotic state, third 
stage, and again, March 13, but without results. 

March 14, the somnambulistic stage was reached in hyp- 
nosis, and next day the man's headache was much relieved as 
a result of the suggestion offered. He was again hypnotized 
and the following day, March 16, the headache had vanished 
and the man was in general much improved. In somnambu- 
lism the disappearance of the analgesia was suggested, and it 
proved possible to make the man walk about without limp 
and without dragging the right foot. Next day the anal- 
gesia was much relieved. In somnambulism the suggestions 
were repeated. 

March 18, the man said he was quite well, and proved to be 
so on examination, except that he could not yet taste with 
absolute normality on the right side. In somnambulism it 
was further suggested that the cure was a perfect one and 
included the sense of taste. However, March 25, the ex- 
pected improvement had not yet occurred in the taste, 
whereupon further suggestions were given in hypnotic som- 
nambulism, re taste. Next day taste had become normal. 

Re hypnosis, Tombleson says that the most successful 
cases of hypnosis are those of Shell-shock psychasthenia, but 
that he gets very good results with hyperthyroidism and 
with neurasthenia also. He goes so far as to say that prac- 
tically all cases of war neurasthenia and psychasthenia can 
be cured and sent back to work if treatment by hypnotic 
suggestion is used in a reasonable time. 



TREATMENT AND RESULTS 76 1 



Neurotic symptoms : Improvement under repeated 
hypnosis. 



Case 546. (Tombleson, September, 191 7.) 
A private, 32, was admitted, April 15, 19 16, to Tombleson's 
ward from the Cottonera Mental Ward with the diagnosis: 
psychasthenia with paresis of right arm. The man was very 
suspicious of the medical profession, melancholy, morose and 
prone to tears. He had been kicked by a horse four years 
before and showed a depressed and very tender scar in the 
right parietal region. The right side of the body since that 
injury had been getting weaker, but the arm was much 
weaker than the leg. Anesthesia was practically complete 
on the right side. There was a wasting of the muscles of 
the right arm and the skin of the hand and fingers was thin 
and shiny. 

Before his transfer the man was placed in the somnambu- 
listic state, with suggestions of happiness and confidence in the 
coming cure. He arrived at Valletta, April 16, in a cheerful 
frame of mind, stating that there was nothing now the matter 
but weakness. Under somnambulism the loss of symptoms 
was suggested and, April 17, the patient was well except for the 
loss of power in the arm and leg. Daily training under som- 
nambulism was given for a period of seven days, with sug- 
gestions especially leveled at the paretic muscles. He was 
then so far recovered that hypnotic treatment was stopped. 
The patient went to England, May 12, 19 16, well. 



762 TREATMENT AND RESULTS 



Convulsions, " Jacksonian," and dysbasia: Cure 
by hypnosis. 



Case 547. (Tombleson, September, 1917.) 

A private, 18, was admitted to hospital, March 22, 1916, 
with the diagnosis Jacksonian epilepsy, with marked func- 
tional gait. He had just had several fits — two March 20, 
two March 21, and several earlier. He was tremulous and 
could not stand. Much pain. Knee-jerks brisk. 

There was a history of a fall into a harbor at seven, fol- 
lowed by bleeding from nose and ears and unconsciousness 
for a week. Convulsions, involving the face, arm and leg, 
and attended by unconsciousness, kept recurring until twelve. 
Five months before admission there had been cerebrospinal 
meningitis. In February at Salonica he had had pneumonia. 

March 23-24 the soldier was hypnotized to the third stage, 
but he had two fits. A " funny feeling in the right big toe " 
was brought out and suggested away. March 26-27 the 
patient was able to walk with a typical functional disorder. 
Under somnambulism the suggestions were repeated, but on 
the evening of March 27 two more convulsions appeared. 
In somnambulism he explained that he " had got round " 
the inhibition of the aura. 

The night of April 2 occurred two convulsions. April 5, 
the man was placed in the somnambulistic stage to last three 
days. During the night of April 6 he was observed to be 
restless for an hour, with some twitching of the right face, yet 
no fit followed. The morning of April 8 the patient woke 
feeling well. He was again placed in somnambulism to last 
two days. Two hours later, however, a fit started. It was 
stopped at once by suggestion, but the patient woke. He was 
left awake the rest of the day. April 9, somnambulism: 
suggestions repeated; sleep to last for two days. That 
evening there was a slight beginning of a fit, which was 
stopped at once by suggestion, the patient waking April 11 
in another beginning of a fit, stopped by suggestion. 

Thereafter no more fits recurred at all. May 12,^1916, well. 



TREATMENT AND RESULTS 763 



Agoraphobia: Cure by hypnosis. 



Case 548. (Hurst, 191 7.) 

A captain was (with one lieutenant) the sole survivor 
among his battalion officers at Ypres. The captain received 
the D. S. O. for his gallant conduct in saving the remnant of 
his battalion. He now felt he could never face responsi- 
bility again and that he would disgrace himself if he ever got 
into danger. He developed a terrible dread of open places 
and became more and more depressed. When he heard that 
there was going to be an attack at Neuve Chapelle, he broke 
down but managed to get through the first day of the battle. 
He was worse off than ever in the evening, felt that he could 
not face another day's fighting, was invalided home, and 
arrived in a condition of exhaustion and feeling of disgrace. 
He had bad dreams at night. Rest was insufficient to restore 
confidence. Hypnosis was followed by rapid improvement, 
and the man was soon able to get back to duty. 

Re agoraphobia, see Section A, XI, Psychopathoses, and 
also Steiner's case (182) of claustrophobia, in which shells 
were preferred to safety in a tunnel. 



764 TREATMENT AND RESULTS 



Stress on Eastern front; cardiac seizures; cellu- 
litis: In convalescence, manual tremors. Treat- 
ment eventually by forcing and isolation. 



Case 549. (Binswanger, July, 1915.) 

A subaltern officer, 24, in civil life a student of mathematics, 
had serious hereditary taint on both sides (father, alcoholic; 
maternal grandfather, victim of " severe nervous disease "). 
As a boy he developed normally, and was a good student. 
He served as volunteer in 191 1 to 1912, but in drill in 1913 he 
had had to be released from service on account of nervous 
heart and difficulty with respiration. 

However, he was called to the colors at the outbreak of 
the war, and was subjected to tremendous strain in the 
eastern campaign; and he was put in the pack train at the 
end of November for cardiac seizures. He had a cellulitis 
with furunculosis following, and at the beginning of December 
there was suppuration of the whole right tibia. He was 
treated in hospital and slowly recovered. 

At the beginning of March, 19 15, without obvious exter- 
nal cause, while sitting in a cafe, the convalescent officer felt 
a cramp in his right hand, and strong movements of the hand 
to right and left followed. He was treated with bromides, 
but unsuccessfully. The tremors became more marked and 
then again from time to time grew weaker. Electric treat- 
ment increased the shaking to a maximal degree. April 27, 
the patient was brought to the nerve hospital at Jena. 

The patient was a fat and muscular man, of average size, 
with very small ears and poorly-developed, adherent lob- 
ules, and syndactylism of the second and third toes of both 
feet; reflexes increased; marked dermatographia ; a static 
fine tremor with rapid oscillations. The tremor became a 
positive tonus if the arm and hand were stretched out hori- 
zontally. Face and chest reddened easily. 

Whenever any other voluntary movement was carried out 
(even slight finger movements of the left hand or of the right 
or left foot while lying in bed) this right-sided convulsive 



TREATMENT AND RESULTS 765 

tremor immediately disappeared. The movements could also 
be made to disappear by slight turning movements of the 
head or of the tongue. Moreover, when the mind was 
diverted, as in reading, the tremors ceased. When the 
patient thought intensely of some mathematical problem, he 
could bring his shaking to a stop. The left grip was stronger 
than the right. In the Romberg position there was a marked 
swaying to the left and backwards. 

Subjectively, the patient complained of nothing but a 
circumscribed headache in the left parietal region and of 
sleep interrupted by frightful dreams. At first the condition 
remained unchanged. There was much insomnia, and the 
slightest noise caused fright. Headaches in the daytime also 
were produced by any noise, and these headaches were 
localized in the left parietal region. The tremors of the 
right hand persisted except as he caused them to stop as 
above mentioned. He could write well with his left hand. 
He would drum with his left hand on the table until the tremor 
of his right hand disappeared. He could play on the piano, 
playing first with the left hand until the right had become 
quiet. He was a very irritable man, passing into anger and 
extreme profanity at the slightest occasion, and it was very 
difficult to bring him to any kind of orderly activity or per- 
sistence in therapeutic measures. These consisted of baths, 
massage, and gymnastics, but they proved quite unavailing. 

As the fellow got more and more intolerable, and as upon 
May 27 at about 9 o'clock in the evening, he disturbed the 
quiet of the entire hospital by a severe paroxysm of scolding, 
he was placed in a single room in the psychiatric department. 
He was placed in bed, cut off from all communication with 
others, and forced to carry out his exercises. 

For two days he was surly, crabbed and obstinate, but 
then changed his demeanor completely; he became friendly 
and obedient. The tremor completely disappeared. 

Five days later he was able to carry out all active gymnas- 
tic exercises with great energy and without the slightest dis- 
turbance in the right arm. At date of report he was busy in 
the garden. 



766 TREATMENT AND RESULTS 



Five weeks' field service: Loss of speech. Cure 
by verbal and electric suggestion in three weeks. 



Case 550. (Scholz, December, 1915.) 

A grenadier, 21, of healthy stock, physique, and habits, 
lost his speech, April 15, 191 6, five weeks after going into the 
field. May 5, examination showed him a well-nourished 
healthy man (lively reflexes and slight dermatographia) , able 
to communicate only by signs and writing. The laryngo- 
scope showed almost complete immobility of the two vocal 
cords, which lay in the cadaveric position, as in paralysis 
of the recurrent nerves. In endeavoring to pronounce the 
vowels a and ee the cords trembled but failed to move toward 
each other. The patient's effort to speak was such that his 
head soon got deep red and sweat streamed from the forehead. 

Speech exercises were started by passing the electric 
current through the larynx during the processes of laryngos- 
copy. The patient was meantime assured that his larynx 
was healthy and that he would soon learn to speak again. 
At the first sitting, the patient felt himself able to cough 
aloud. 

After a few days, the patient was able to speak the separate 
vowels tolerably well, and was then made to go on with such 
words as Anna, Otto, Hurrah. The vocal cords began to 
move better. Fatigue was a feature of the first treatments, 
of such a degree that words that could be pronounced during 
the first part of the sitting were lost toward the close. 

The grenadier assiduously set himself to say over and over 
again the words that he had learned, and would come to the 
sister radiant with joy at his success. In ten days he was 
able to speak again perfectly, though giving the impression 
of a slight stuttering. After three weeks hospital stay he was 
discharged cured and fit for service. 



TREATMENT AND RESULTS 767 



Struck by a rifle butt on right side of head; old 
wound of right thigh: Hysterical right hemiplegia 
and deaf mutism. Treatment by faradization : Re- 
turn of speech and improvement of hearing. Full 
recovery by suggestion. Hysterical CONVUL- 
SIONS developed BY HETERO SUGGESTION 
from convulsive neighbor. 



Case 551. (Arinstein, 1915.) 

A Russian corporal, 21, was knocked unconscious, Sep- 
tember 13, 1915, by a butt of a rifle which struck the right 
side of his head. He came to in a short time. He was 
examined in hospital, early in October, and besides a small 
skin wound of the head, there was evidence of a wound on 
the anterior aspect of the thigh. There was paralysis of both 
right arm and right leg, and anesthesia of the entire right side 
of the body, face and even of the tongue. There were also 
pains over the whole right side of the body. The abdominal 
reflexes were present on both sides; the tendon reflexes were 
in excess on the hemiplegic side; there were no pathological 
reflexes of any sort. The patient's hearing was diminished, 
and he could not speak at all although he could understand 
the speech of others perfectly. 

Speech returned after a single seance of suggestion with 
faradism to the throat. Hearing began to improve. The 
patient's suggestibility was a favorable factor in his cure, 
but there were some unfavorable features. One day, he saw 
a neighbor go into convulsions and proceeded to develop 
convulsions himself. These hysterical convulsions continued. 
According to Arinstein, such undesirable complications ap- 
pear under conditions of extreme crowding of hospital pa- 
tients suffering from shell-shock. Progressive seances of 
psychotherapy caused the disappearance of all the signs of 
paralysis, and at the time of the report, there was no dis- 
ability, except that the full use of the hand had not yet been 
regained. 



768 TREATMENT AND RESULTS 



Shell-shock and burial; labyrmthine disease on 
one side : DEAFMUTISM. Cures, relapses and 
eventual cure by general anesthesia, more than four 
months after shock. 



Case 552. (Dawson, February, 1916.) 

A private, 30, had been 12 years in the service. July 8, 
191 5, he was partially buried by a shell which killed two 
companions. 

On admission to hospital he spoke a few sentences but 
was deaf, and next morning could neither speak nor read, 
nor did he take food for 36 hours thereafter. 

Admitted to the King George Hospital, July 18, he was 
found stuporous, but started violently if touched, made 
signs indicating his wants, took no interest in surroundings, 
and resisted efforts to arouse him. He was without signs of 
organic disease. It seems that he had been a nervous child, 
with nightmares and fits. 

July 24, he was given gas for dental extraction, partly in 
the hope that he would recover speech; but though he 
struggled violently, he made no sound. He had by this 
time become rather intelligent in a childlike manner, being 
pleased to see his small boy, but taking no notice of his wife. 
Ittranspired afterward that he did not recognize her. 

Phonation in whisper now began. There was then a re- 
lapse, and for a week or more no food was taken. Such 
relapses with irritation and hypobulia and an obstinate 
constipation recurred; but improvement came on slowly. 
He became able to read short printed words, and later 
handwriting. 

For another month there was no improvement and he 
lost heart and the will to get well, brightening up only when 
offered a motor drive or something else pleasant. He was 
transferred to an auxiliary hospital, against his will, Sep- 
tember 18. 

November 1 , he was brought back to the King George Hos- 
pital, excited, shouting, struggling and evidently drunk. On 



TREATMENT AND RESULTS 769 

a day's leave from the convalescent hospital he had come up 
to London, and in alcoholic elation began to laugh and talk. 
Morphia did not reduce his violence. He insisted on seeing 
the physician, to tell him the good news. Hearing was still 
diminished, though if attention were diverted, direct answers 
were given to some questions. Sleep followed. 

The next day he spoke perfectly but could hear nothing. 
There was no further progress for three weeks, though he 
occasionally caught sounds. He now became bright and 
pleasant and had lost all irritability and sulkiness. Galvanic 
and faradic current had no effect on the ears. 

November 27, after elaborate preparation to heighten the 
suggestive effect, the patient was kept in bed and given gas 
and ether up to the abolition of the corneal reflex. As he was 
coming round, the doctor shouted that he could now hear well. 
He was overcome with joy and had hysterical convulsions. 
He could hear, but with the right ear only. In point of fact, 
the left ear on examination showed signs of labyrinthine deaf- 
ness. He was placed on home service. 

Re etherization for functional deafness and mutism, Ninian 
Bruce maintains that ether is more satisfactory than chloro- 
form. The loss of consciousness in cases of deafness and 
mutism ought to be a relatively slight one, and the patient 
should be suddenly roused to the realization that he is speak- 
ing. Recovery from chloroform anesthesia is, according to 
Ninian Bruce, too slow to allow the patient to catch the 
point that he is now speaking and hearing when he was 
formerly dumb or deaf. A failure with the method is a bad 
thing for the patient, as he loses confidence in the method, 
whereupon some other method must be resorted to. 

Re etherization for deaf mutism, see technic of Ninian 
Bruce under Case 553. Penhallow has a case in which 
during primary etherization the patient reviewed in a loud 
voice the whole story of his speech loss. He was found to 
have recovered speech and hearing after coming out of ether. 

Re anesthesia by gas, Abrahams has used nitrous oxide for 
cure of hysterical paraplegia. Proctor also reports the use 
of light ether anesthesia for bringing out the voice of func- 
tional mutes. 



770 TREATMENT AND RESULTS 



Shell-shock functional deafness (five months). 
Yes-No test. Cure by suggestion on emerging 
from ether anesthesia. 



Case 553. (Bruce, May, 1916.) 

A soldier was admitted to the Royal Victoria Hospital, 
Edinburgh, completely deaf in the left ear. He had been 
under shell fire a number of times in France and was eventu- 
ally thrown down and made unconscious by a shell explo- 
sion on his left. He did not remember the noise of the 
explosion or anything until he found himself in hospital. 
After the explosion he had begun to stutter, and the stuttering 
had grown worse. Examination of the ear indicated that 
the deafness was functional. He was given ether and when 
just under was asked if he could hear anything spoken in his 
right ear. He said, " Yes." With the right ear closed he 
was asked if he could hear when his left ear was spoken into. 
He said, " No." This test was repeated several times. 
After covering his right ear, he gave his name, regiment, 
etc., in reply to questions whispered into his left (previously 
deaf) ear. The incongruity was pointed out. He was now 
suddenly wakened. He laughed hysterically with joy over 
his recovery. 

But the next morning he was again stone deaf in the left 
ear. Blistering and electricity failed to produce benefit. He 
was, however, puzzled about himself. 

After a fortnight he was again given ether and a little 
chloroform was added. The yes-no test was again positive. 
He was allowed to recover gradually from the chloroform, but 
he had now lost recollection of what had happened. The 
left ear remained deaf. Ether was again given. He was 
asked to close his right ear with his finger. While answering 
questions addressed to his left ear, he was suddenly awakened 
and immediately said that his hearing had come back. 
This return proved permanent. He returned to his depot. 
In the conversations under ether there was no stuttering. 
He had been totally deaf in the left ear for five months. 



TREATMENT AND RESULTS 77 1 



Blow in neck by rifle butt: aphasia, right hemi- 
plegia and hemianesthesia, and especially (here 
MEDICAL suggestion) trismus: Recovery by an- 
esthetic and suggestion. 



Case 554. (Arinstein, September, 19 15.) 

A Russian soldier was struck in the head and neck by a 
rifle butt, and developed paralysis of right arm and leg with 
loss of speech. After the excitement experienced by the 
patient when exhibited to the students by the late Prof. M. N. 
Szukowsky in the neurological clinic of the Military Medical 
Academy, trismus developed. 

The patient spent a year in various hospitals, the most 
diverse methods of treatment by drug therapy, electricity, 
and suggestion yielding no results. The patient had to be 
fed chiefly by nose and rectum, though small quantities of 
fluids were fed through the mouth through an opening formed 
by the falling out of one tooth in the upper jaw. The patient 
became greatly emaciated and weak and was, October 29, 
191 5, brought into the nervous wards of the hospital. 

He showed flaccid paralysis of left arm and leg, together 
with anesthesia, analgesia and thermanesthesia over the whole 
left side of the head, extreme general atrophy of muscles, 
somewhat more marked on the palsied side. The tempera- 
ture of the paralyzed half of the body was not lowered. No 
knee or Achilles reflex obtained upon either the affected or 
the healthy side (general exhaustion?). Abdominal and 
testicular reflexes lively. The pupils responded well to 
light. Corneal reflexes lively. The neck was held awry to 
the left, and the head was inclined somewhat downwards and 
leftwards; hearing on left side impaired. The jaws could 
not be opened even with the greatest effort. Wassermann 
reaction negative. 

Patient thought himself incurable. Purves Stewart's case, 
in which chloroform and oxide of nitrogen were used, was the 
basis of Arinstein's treatment. It was suggested to the 
patient that he submit to narcosis with the proviso that he 



772 TREATMENT AND RESULTS 

would not be operated upon. His consent was secured; 
with the cooperation of others, the chloroform was adminis- 
tered November 6. The stage of excitability was not well 
marked. 8 gr. of chloroform was used altogether, by the 
drop system. Nevertheless, even with the weak initial 
excitability, the patient became capable of some movements 
with paralyzed hand and foot. On opening mouth, the 
patient yawned yet uttered no sound. Between the jaws 
was put a rubber insertion and upon awakening the patient 
was let see with his own eyes that his jaws were open and that 
therefore food might be introduced through the mouth. 
Upon repetition of the narcosis, 5 gr. of chloroform was used 
altogether, and the stage of excitability was this time better 
marked. To strengthen movements in the paralyzed ex- 
tremities, the device of pricking the patient with a pin on 
the unaffected half of the body, with the unaffected hand and 
leg held horizontal by assistants, was adopted. The patient 
then made reflex defensive movements in the paralyzed 
extremities, especially the hand. At this point the narcosis 
was suspended, and the irritation with the pin was con- 
tinued until consciousness returned. At this moment, the 
patient's attention was called to the disappearance of the 
paralysis and his restored ability to move the paralyzed ex- 
tremities. 

From that time on, the patient's condition underwent a 
sharp transition. Artificial feeding became unnecessary. 
The patient ate by mouth; the mouth was opened by the 
leverage of a small stick held by the patient between his teeth. 
Speech returned gradually. In reading aloud the patient 
aided the movements of his lips with his hands. At the 
time of report the patient spoke well, ate normally, had gained 
in weight, and with some effort could sit down and even stand 
and walk. All this was attained in a relatively short time 
after a whole year of paralysis. 

The author felt that the success attained in this case gave 
him the right to use the same method where the cause was 
not a contusion. 



TREATMENT AND RESULTS 773 



Ten months' field service; severe FEBRILE DIS- 
EASE : Afterward hysterical TRIPLEGIA, MUTISM, 
11 JUMPING- JACK " reactions to stimulation of 
feet. Cure by anesthesia, verbal suggestion, 
faradism to palate. 



Case 555. (Arinstein, September, 191 5.) 

A Russian private, 30, brought to a field reserve hospital, 
June 20, 1 91 5, was in a grave condition diagnosed typhoid. 
By the end of June the general condition had improved and 
the temperature had fallen. 

July 9, worse; happening to be in the company of a sanitary 
in a privy, he was observed suddenly to fall unconscious, 
with both feet and left arm paralyzed. Soon afterward he 
lost the power of speech. From September 30 to October 
19, he lay in field hospital; but was then transferred to the 
nerve hospital with diagnosis: convulsive paralysis and 
aphasia. At entrance, complete paralysis of both legs and 
left hand; loss of speech and aphonia (speech understood). 
Upon touching a foot, strong convulsions developed with legs 
rapidly drawn apart and drawn together much in the man- 
ner of dancing toys. The mouth was twisted to the left. 
Though he silently opened his mouth and made rapid move- 
ments with the lower jaw, he could not utter a single sound, 
either vowel or consonant. Left hypalgesia. Hypesthesia 
of skin of hand and mucosa of tongue. Knee-jerks absent 
because of the strain of the muscles of the legs. Wassermann 
negative. 

The history showed that the speech of the patient had been 
incorrect and indistinct from childhood. Moreover, in 1908, 
in chopping wood in the forest he had fallen under a sleigh 
and hurt his left hand, which had not since fully recovered. 
He had volunteered for the war. 

The psychogenic character of the disease seemed clear. 
Suggestion was followed by ether narcosis, during which, on 
pricks of the healthy side with a pin, the patient made 
defensive movements with the paralyzed hands, and also 



774 TREATMENT AND RESULTS 



moved both legs. Speech was not regained either during 
or immediately after the narcosis, although the patient gave 
forth indefinite sounds. Speech was restored on the same 
day, September 7, with verbal suggestion and faradic brush 
applied to palate. The patient at once began to speak 
clearly and distinctly, read his prayer book, and described 
distinctly and in detail how he went to war. From that 
moment the convulsive movements in the feet disappeared, 
the region of anesthesia on the left side narrowed, speech 
was permanently reestablished, and the patient began to 
move with his feet and finally began to walk after six months 
of paralysis. Before that time no medical treatment had had 
the slightest effect. The effort to stop mechanically the 
jerks even temporarily by means of plaster casts had been 
unsuccessful. In sleep the twitches ceased, but upon re- 
awakening, even before full consciousness returned, the 
jerkings would resume. It is curious to note that upon 
falling asleep under the anesthetic the patient would issue 
always one and same kind of yells — "Help, there goes the 
German ! They are shooting ! Russians, do not yield ! 

Re chloroform anesthesia, Milligan remarks that the treat- 
ment should be carried out in a quiet, single room, with the 
chloroform slowly administered and the suggestions made 
by the anesthetist during the optimal phase for suggestion, 
— just before the stage of involuntary struggling. 



. 



TREATMENT AND RESULTS 775 



Shell-shock ; unconsciousness : Mutism and musi- 
cal alexia. Cure by anesthesia. 



Case 556. (Proctor, October, 1915.) 

A private, 23, was admitted to the Duchess of Connaught's 
Hospital at Taplow from Gallipoli, September 10, 191 5. 
A shell had exploded behind this man. He had been picked 
up, unconscious, and remained so about a day. He re- 
covered without the power of speech. Cerebration was slow 
at first but improved steadily. 

The man had been a professional musician. Curiously 
enough, though his ability to read ordinary print was as good 
as ever, his reading of music was lost with the speech. 

September 20, he was etherized, but being of a phlegmatic 
type, he was not readily excited and took the anesthesia very 
quietly. After perseverance, however, he was induced to 
talk. The ability to read music returned with the voice. 
He was discharged, October 4, 191 5. 

Re the use of anesthetics for curing deaf mutism, Colin 
Russel rather disapproves of this method on the ground 
that no attempt is made to get at the genuine pathogenesis 
of the case and that accordingly there may be a tendency to 
recurrence. 

Re the peculiar musical alexia, see discussion under Cases 
353 and 450 of confusion and amnesia. The most highly 
selective amnesias have been found in confusional cases. 
However, Case 556 had been a professional musician and 
the effect may have been a highly specialized suggestion. 
See also Case 369 of Feiling for differentiated musical dis- 
order. Mott has used the retained knowledge of tones as 
an avenue of approach in certain mute cases. 



776 TREATMENT AND RESULTS 



Shell-shock ; burial (24 hours ?) ; unconsciousness, 
13 days : Deaf mutism. Chloroform narcosis cured 
the deafness (!), not the mutism. 



Case 557. (Gradenigo, March, 191 7.) 

An Italian infantryman was buried under Mt. Zebio after 
shell explosion. After 24 hours he was found and dug out. 
He remained unconscious for 13 days and came out abso- 
lutely deaf and mute. 

At hospital he was markedly depressed and cried very 
readily on being spoken to. The tympanic membrane had 
lost its sensitiveness to pain. As for the speech mechanism, 
the larynx proved negative. All the movements of the soft 
palate, tongue and vocal cords could be normally performed. 
The tongue was anesthetic to touch, but the taste function 
was perfectly preserved. The cheeks and various parts of 
the face were also anesthetic to touch, and the lobules of the 
ears could even be pierced with large pins without reaction 
by the patient. 

He tried to pronounce labials, opening and closing the lips 
rapidly; but the expiratory movement was^too weak, and 
not a single sound was made. 

At the patient's request, he was chloroformed. During a 
very violent excited phase, he did emit groaning sounds. 
The narcosis, however, did not put an entire stop to the 
mutism, since only a few inarticulate sounds could be emit- 
ted, and those only after great efforts. Curiously enough, 
however, the chloroform narcosis had caused the deafness to 
disappear entirely. Another narcosis upon the patient's 
insistent request was given but remained without results, 
and at the time of report, the patient though cheerful and 
intelligent-looking, was still mute. 



TREATMENT AND RESULTS 777 



Treatment of two cases. 



Cases 558 and 559. (Smyly, April, 1917.) 

A soldier was out with a bombing party when a shell burst. 
He came to in a casualty clearing station, and was sent on to 
Salonica, deaf, dumb and jumpy. Two months later, an 
attempt at hypnosis failed; faradism of vocal cords failed. 

The patient dreamed one night that if he vomited he could 
speak. Ipecac produced vomiting without speech. The 
patient, however, wanted a second dose, and while waiting 
for it, uttered an exclamation, which he did not himself hear, 
however. In the meantime, Dr. Smyly had been trying to 
hypnotize a second soldier, dumb but not deaf. This man's 
dug-out had been blown in on him seven months before, 
whereupon the patient became very shaky, but did not be- 
come sick for a week. He was then sent to hospital, and his 
voice gradually disappeared. He suffered from violent 
headache and spasmodic movements of the arms and legs. 
Suggestion seemed powerless, and ether was unexpectedly 
given to the patient. While going under the ether, he said, 
" Oh dear, oh dear " several times indistinctly. It seems 
that another physician had already tried to cure the patient 
of dumbness by removing teeth without an anesthetic. 

While this therapy was proceeding with the dumb man, 
the deaf-and-dumb man disappeared. It seems that the 
smell of the gas had caused him to take refuge on an out- 
house-roof. The next day he had recovered voice and 
hearing completely, partly from shock and partly through 
suggestion. 

The etherized patient did not recover voice but lost the 
spasmodic movements and his insomnia. A week later 
ether was again administered, and the patient was strapped 
down; as he was coming to, faradism was applied to the head 
and face. The patient then quickly recovered his voice and 
still retains it. 



778 TREATMENT AND RESULTS 



Shell wound: Hysterical dysbasia from contrac- 
ture. Many methods of treatment fail. Success 
with " a new measure,' ' e.g. stovaine. 



Case 560. (Claude, March, 1917.) 

A sergeant was struck in the suprapubic region, December 
15, 191 5, by a shell fragment and got a large hematoma in 
the perineal region (shell fragment visible on X-ray). The 
man was treated a year in a center for physiotherapy and was 
then treated in a neurological center, where a faulty position 
of the right thigh maintained in extensor rotation and ab- 
duction was found. The patient walked on crutches, legs 
wide apart, balancing with body. 

Upon transfer to Bourges, an intraspinal injection of sto- 
vaine (after withdrawal of 2-3 cc. fluid, 1 cc. stovaine, 
0.07 to the cc, mixed with cerebrospinal fluid) was made. 
This reduced the contracture and permitted the patient to 
place his legs parallel. They were then bandaged in the 
parallel position. The bandages were removed two days 
later and the limbs did not reassume their faulty position. 
The man was shortly able to walk with a cane ; progress was 
rapid. This man was very desirous of cure and refused 
to be invalided, believing he was to be cured, and had re- 
ceived medal and war cross. Simple motor reeducation in 
competent hands had been without effect. A new kind of 
measure, such as stovaine, proved successful. 

Re "new measures" for hysteria, see items under Case 
516. See also remarks upon cures by lumbar puncture under 
Case 488. : ' ' 



TREATMENT AND RESULTS 779 



Burial: Hysterical dysbasia. Treatment by sto« 
vaine anesthesia. 



Case 561. (Claude, March, 1917.) 

A chasseur, buried June 24, 19 16, had a number of general 
symptoms, apparently got well and was given seven days' 
leave at home. On the way he felt abdominal pain which 
he thought due to the jolting of the car. Suddenly he felt his 
legs trembling on extension. He left the train and went into 
a hospital where a diagnosis of radicular and spinal lesions 
was made. Two months later he was sent to Claude who 
found that he could walk only with knees flexed. If he was 
requested to stand up and extend his legs on the thigh, a 
trembling set in suggestive of an epileptoid trepidation. 
Even in the horizontal position the same clonic trepidation 
occurred which only stopped if the patient flexed his legs on 
the thighs. 

However, no sign of organic lesion could be found. There 
was an analgesia limited to the ankles. Psycho- physio- 
therapeutic treatment was unavailing. January 28, 1917, 
the sto vaine injection method was tried. After anesthesia 
had set in, it was found possible still to produce the spastic 
state by extending the legs; but a half hour after injection 
the spastic state could no longer be produced. The patient 
was shown that the trepidation was abolished. During the 
period of return of sensibility, the legs were constantly moved 
and the patient constantly told to make movements himself. 
He was convinced of his power. There was no longer any 
clonus. The patient remained all day in bed without epilep- 
tiform movements. Next day he complained merely of 
weakness in the legs and was got to walk without having 
convulsive tremors. During the next few days he began to 
walk with a cane, later without support, and there were no 
more contractions except transiently in the left leg if the 
patient walked a little too long. He left the hospital cured. 



780 TREATMENT AND RESULTS 



Shell-shock deaf mutism : Psychic treatment. 



Case 562. (Bellin and Vernet, January, 1917.) 

A soldier in a colonial regiment was sent, August 14, 191 6, 
to an evacuation post with a diagnosis " deafness following 
shell-shock, unfit for service." The patient asked that he 
be spoken to very loud because he could not hear, and he 
himself spoke in whispers. He kept watching his interlocu- 
tors' lips and moved his own as if to pronounce the words. 

A shell had burst nearby fourteen months before in June, 
191 5. After being in several hospitals, he was sent to an 
oto-rhino-laryngological service where he had his hearing 
reeducated and was taught lip reading. It was soon per- 
ceived that he could hear without lip reading and he was 
assured that he could be cured at once, but naturally he was 
not convinced. He produced a carefully filed paper stating 
11 atrophic ozenous rhinitis, deafness from labyrinthine shock 
following shell explosion, hearing diminished 60 per cent right, 
30 per cent left." 

However, energetic psychotherapy was started and in the 
absence of electricity, subcutaneous injections of ether were 
given. Such patients had always been cured, and a drug 
injected under the skin, not dangerous but extremely painful 
would cure him! This treatment was carried out in a dugout 
near enough to the lines to be daily " potted." The patient 
was left for a space to reflect, and he finally accepted the 
chance of cure. He was exhorted to stand courageously the 
pain and to breathe deeply and to repeat a word more and 
more loudly. Finally he was made to speak normally and 
eventually to cry out loudly. He now felt much astonished, 
and in his astonishment forgot his deafness. He said that 
he had never spoken or heard since the accident, that he had 
been a deafmute from the first month of his illness, and that 
for the last three months he had been able to speak only in 
a whispered voice. 

He should have been watched a few days to confirm the 
cure. This was impossible in the crowded dugout and no 



TREATMENT AND RESULTS 78 1 

risk could be run of his escaping. Kept over night he w&s- 
found next day unable to hear and talking in the same 
voice as before. 

He was now found to be either an exaggerator or a simu- 
lator. He was given a half hour to exercise his voice in and 
told that he must succeed unless he was a simulator. At 
the end of half an hour it was found that he had skipped. 
He was sent back by the division surgeon with orders to send 
him to the otological service for inquiry. The otological 
service found an atrophic ozenous rhinitis, a normal larynx, 
perfect audition. He was given a psychic X-raying and a 
few electric sparks were also drawn from his neck. He then 
began to talk in a loud voice and to hear normally. August 
30, he was sent out completely cured and rejoined his regi- 
ment. 

Re treatment of deafmutism by other means than pseudo 
operations and anesthesia, see remarks under Case 556 con- 
cerning Colin Russel's opinion that anesthesia does not get 
at the true genesis of cases. Re the teaching of lip reading 
to Shell-shock deafmutes, see discussion under Case 580. 



782 TREATMENT AND RESULTS 



Brachial monoplegia. Cure by electrical suggestion 
(physician bored-looking, brief, and authoritative). 



Case 563. (Adrian and Yealland, June, 191 7.) 

Adrian and Yealland had occasion to treat an officer with 
a persistent functional paralysis of the arm, which had suc- 
cessfully withstood hypnotism, psychoanalysis, rest, massage, 
anesthesia with ether, and painful electrical treatment. 

This patient knew something of the functions of the brain 
and was prepared to discuss his condition exhaustively. He 
was told, however, that he had come to be cured and that 
the nature of his cure would be explained to him afterwards. 
Without further discussion, the motor areas of the cortex 
were mapped out rapidly. The measurements were repeated 
aloud to impress and mystify the patient. He was assured 
that as soon as the shoulder area of the cortex was stimulated 
faradically, he would be able to raise his shoulder, and that 
then the rest of his arm would recover. An exceedingly 
mild faradic current was then applied to the scalp for a few 
moments and he was then ordered to move his shoulder. He 
did so at once. In a few minutes, all of the paralysis had 
vanished and the patient could raise 30 pounds. Adrian and 
Yealland believe that the success here was largely due to the 
fact that the patient was not allowed to discuss the case or 
criticize the treatment beforehand. 

It is essential that the patient should be convinced that 
the physicians understand the case and can cure him. No 
physical sign should be examined as if it were interesting or 
obscure. An attitude of "mild boredom bred of perfect 
familiarity with the patient's disorder " is cultivated. If the 
case is exhibited it should be exhibited " as a perfect example " 
of the type of case that is cured in five minutes by appropriate 
treatment. " Rapidity and an authoritative manner are the 
chief factors in the reeducative process." 

Re psychoelectric treatment, see Yealland's book, pub- 
lished while this compilation was going to press, Hysterical 
Disorders of Warfare, 191 8. 



TREATMENT AND RESULTS 783 



Brachial monoplegia following use of sling after 
bruise or wound. Technique of electrical sug- 
gestion and rapid reeducation. 



Case 564. (Adrian and Yealland, June, 191 7.) 

Adrian and Yealland give the following typical case of 
paralysis of the arm as a very frequent and very curable 
form of war neurosis, occurring as a rule after a slight wound 
or bruise necessitating the use of a sling. The patient, hav- 
ing received a slight wound of the forearm, for months had 
a useless arm, which he could move but slightly at the 
shoulder on exerting a superhuman effort. Occasionally he 
could flex the fingers through a small angle. There was 
complete anesthesia of the hand and arm of long-glove type. 
This anesthesia was not complained of, and might not be 
noticed until suggested to the patient by the physician. It 
is well to elicit the anesthesia, however, in view of the treat- 
ment to be applied. There was no wasting of muscles; the 
sensory loss was typical of hysterical anesthesia; nor could 
the whole arm have been involved by an injury that did not 
affect the upper arm and shoulder. 

The patient was told that he was very lucky to have come 
off with such a slight injury ; his arm was to be set right in five 
minutes by the application of a special form of electricity. 
He was then made to sit on a large pad electrode connected 
with an induction coil; the other terminal is connected 
with a wire brush. The first effect, he was told, would be 
the return of feeling in the forearm ; power would return 
with the feeling. The wire brush with a fairly strong cur- 
rent was drawn downwards over the forearm from elbow to 
wrist. He was told that he could now feel as far as the 
wrist, and a pin was used to convince him that he could thus 
feel. If he had not felt the pinprick, the current would have 
been increased in strength until he could feel. The hand was 
now treated in the same way. 

He was now told that, as feeling had returned to the arm, 
the power of movement would be restored shortly. Adrian 



784 TREATMENT AND RESULTS 

and Yealland remark that laymen seem to consider that loss 
of power and loss of feeling are inseparably connected. The 
electrode was now used to produce contraction in the mus- 
cles. Under these circumstances, the arm will be used hesi- 
tatingly, with an appearance of great effort; but the patient 
is nevertheless convinced that power is returning. 

"Rapid reeducation follows at once. He is given no 
time to think, but urged to move the arm more and more 
strongly, to grip the physician's hand, to flex and extend the 
elbow, etc., and the pressure is not relaxed until the whole 
arm has returned to its normal vigor. If recovery is station- 
ary, faradization is repeated with stronger and stronger cur- 
rents. If it seems as though he might relapse on leaving the 
hospital, he is told that this is very unlikely, but that if it 
should occur, he should report sick at once and come back 
for treatment with a current far stronger than that already 
used." 

Adrian and Yealland claim that they have applied their 
combination of suggestion and reeducation in more than 250 
cases (including 82 cases of mutism, 34 of deafness, 18 of 
aphonia, 37 brachial or crural monoplegia, 46 paraplegia, 
16 hemiplegia, and 18 of non-organic gait disturbance), and 
that although a majority of the cases have been of several 
months' standing, treatment has been almost immediately 
successful in at least 95 per cent of the cases. 



TREATMENT AND RESULTS 785 



Exposure in the retreat from Mons: Persistent 
hysterical sciatica. Treatment by faradism and 
verbal suggestion. 



Case 565. (Harris, 1915.) 

A soldier developed pains about the hips and down the 
right thigh after getting wet through in the retreat from 
Mons, August, 19 14. He was treated for a period of nine 
months in various convalescent homes and military hospitals, 
incidentally receiving forty baths at Droitwich. He hobbled 
on a stick, leaning upon the left leg and dragging the right 
stiffly. The thigh was tender and hyperesthetic. 

The proper treatment of cases of hysteria, according to 
Harris, is strong faradism, applied by a small electrode or 
wire brush to the moistened skin. The stimulus is made 
powerful enough to force the patient to admit that he feels. 
The theory is that the powerful stimulation "breaks down 
the psychical auto-inhibition which produces the hysterical 
anesthesia." 

Faradism is only the first phase of the treatment. Verbal 
suggestion follows. Building on the basis of the feeling pro- 
duced by the faradism or on the basis of the ocular evidence 
of motion in the hitherto paralyzed muscles, the patient is 
informed that the electricity will now be more and more 
strongly felt and that he will be cured in a few minutes. 

The two elements in the therapy, then, are: encouraging 
verbal suggestion and the suggestion afforded by the para- 
phernalia of a complex looking, noisy machine. The 
knowledge on the part of the patient that a powerful and 
mysterious stimulus, namely, electricity, is being employed 
is a third element of suggestion. 

Persistent hysterical sciatica, such as that of the present 
case, may require prolonged treatment. In this instance, the 
man was completely cured in five minutes, so that he was 
made able to run across the room. He said he would now be 
able to go back to the front, and wondered why he could not 
have been cured before. 



786 TREATMENT AND RESULTS 



Prognosis of intensive reeducation in reflex 
(physiopathic) disorder — complete recovery (ex- 
cept for the hysterical fraction of the disease) not 
expected. 



Case 566. (Vincent, 1916.) 

A young soldier was superficially wounded in the left knee, 
in August, 1914. A year later, he showed amyotrophy of the 
left calf, which measured 2.5 cm. less than the right, a weak 
slow Achilles reflex on the left side, cyanosis and hypothermia 
of the left foot, weakness and limitation of movements in the 
left foot, with slight contracture in flexion of leg upon thigh. 

Thenceforward and for eight months, this soldier was sub- 
mitted at the Tours Centre to intensive reeducation. For 
two hours every day upon prescription he walked, ran, and 
hopped upon the left leg. In September, 19 16, after twelve 
month's training, there was a certain improvement in his 
disorder. The leg was now completely extended upon the 
thigh, and the amplitude in the movement of the foot was 
almost normal; but the amyotrophy, vasomotor disorder 
and certain electrical disturbances remained quite unchanged. 
The man himself recognized that his status was greatly im- 
proved, but he could not walk more than four or five kilo- 
meters without great fatigue. 

In view of the inferior results of reeducation in some of 
these cases, should any attempt at all be made to reeducate? 
Vincent thinks that that should be; but that it should be 
borne in mind that sometimes no results may be obtained. 
If the reflex disorder (in the Babinski sense) is minimal and 
the chief difficulty is hysterical, then sometimes the man may 
go back to service after reeducation ; but in intense examples 
of reflex (physiopathic) disorder, invaliding has often proved 
necessary. 

Re values of intensive reeducation, Vincent's technique 
and results have logical resemblances to those of Yealland 
and of Kaufmann. Vincent established in the 9th district 
neurological center a method of intensive reeducation which 



TREATMENT AND RESULTS 787 

is particularly suited to old hysterical cases. He divides- 
the treatment into three stages: First, the stage called by 
the poilu by the picturesque name of torpillage; secondly, 
the stage of fixation ; thirdly, the stage of training. Accord- 
ing to Roussy and Lhermitte, there are few cases at the 
front suitable for the treatment of Clovis Vincent, which is 
especially devised for the old cases. See under Case 574 
for further details of Vincent's treatment. 

Re prognosis of the physiopathic disorder, there has been 
some controversy in France. See discussion under Case 530. 
Re suitable treatment for physiopathic disorders, Babinski 
and Froment suggested the application of heat. The warm 
bath test is also of value in diagnosis. Babinski and Fro- 
ment claim progressive improvements with hot baths, hot 
air douches, and light baths — but counsel great prudence. 
The improvement is never rapid. 



788 TREATMENT AND RESULTS 



Wound of calf ; operations : hysterical contracture 
with " physiopathic " features. " Brutally con- 
quered " by reeducation. 



Case 567. (Ferrand, March, 1917.) 

A French infantryman, class of 1912, was wounded, May 
12, 19 1 5, in the upper third of the right calf. His posterior 
tibial artery had to be ligated. In a few weeks the wound 
was healed, but he began to walk badly, presenting a con- 
tracture of the calf with retraction of the tendo Achill is. 

Toward the last of 191 5 a surgeon under the impression 
that the disease was organic cut the tendo Achill is but the 
soldier could not walk any better. As he could not take the 
position of equinism, he semiflexed his knee and walked upon 
a crutch. 

Another surgeon was now found to perform a tenotomy on 
the flexors of the leg and put the patient in a plaster cast to 
correct the flexion and immobilize in extension. This second 
operation was in July, 1916. The patient now walked with- 
out a crutch. 

He was then sent to a neurological center, Dec. 8, 19 16, 
walking on two canes, right leg in forced extension on thigh, 
in permanent and absolute contracture. All movements ex- 
cept leg flexion could be executed, though slowly and weakly; 
but positive movements were impossible, except flexion of 
the knees. There was no sensory disorder. Reflexes were 
normal save that the leg reflexes were a little stronger on the 
affected side, and the patellar reflex on that side was nullified 
by the contracture. Electrical reactions proved normal. 
There were marked trophic disturbances of the right foot and 
of the lower third of the lower leg. There was a certain 
amount of edema, cyanosis, coldness and thickening of skin; 
marked muscular over-excitability of the distal extremity of 
the leg. In short, Ferrand was here dealing with a case of 
Babinski's group of the so-called physiopathic cases. The 



TREATMENT AND RESULTS 789 

man was somewhat feeble-minded, and anxious and a trerfp 
bling suppliant for cure. 

He was put, December 15, in a reeducation room and by 
means of fatigue, induced by violent physical exercises, was 
(Ferrand states) "brutally conquered." The contracture 
after a half hour of physical movement of flexion and ex- 
tension of the leg ceased. The patient was shown how he 
could himself both flex and extend the limb himself; he was 
then caused to do this spontaneously. These active move- 
ments were aided and at times provoked by somewhat pain- 
ful galvanic discharges. The patient then walked slowly, 
and flexed both knees to the maximum. He was cured after 
a treatment of 2§ hours. There were, of course, some (sur- 
gical) intra-articular adhesions in the knee and it was neces- 
sary for the patient to break these adhesions. An X-ray 
had shown the bone to be intact. A slight hydrarthrosis 
developed the next day, but a few days later he was able to 
walk as well as anyone. For five weeks he followed a train- 
ing platoon in the reeducation work and was evacuated, 
January 23, 191 7, to his station, though he had entered the 
neurological center with the idea that he was to be invalided 
with a pension. 

He had a few relics of physiomotor disorder when he left, 
including the abnormal delicacy of skin and muscular over- 
excitability above mentioned. On the basis of this and sim- 
ilar cases Ferrand believes that, although the physiopathic 
group of Babinski exists, it does not signify a separate clinical 
syndrome and the occurrence of physiopathic symptoms does 
not contraindicate psychotherapy. 

Re this controversy, see remarks under Case 530. 



790 TREATMENT AND RESULTS 



Shell-shock : Paraparesis. Cure by electricity. 



Case 568. (Turrell, January, 1915.) 

Turrell, in a paper on electrotherapy at a base hospital, 
narrates a case of spinal concussion which rapidly yielded to 
the persuasive influence of Bergonie's machine for electri- 
cally provoked exercises. Turrell grants that such a rapid 
cure would probably be attributed to suggestion, but thinks 
that the term demonstration might be preferred on account of 
the vigor and amplitude of the muscular contractions excited. 

This soldier was driving an ammunition wagon at the 
front, when a shell exploded under the wagon, killing one 
horse and severely wounding the other. The patient him- 
self was blown into the air, fell, dragged himself to a trench 
where he lay all night, and found himself in the morning 
unable to walk or stand. He recalls that pins were stuck 
into his legs by the examining medical officer and that they 
produced no sensation. When he was finally brought to the 
Third Southern Medical Hospital, he was unable to draw up 
or move his legs, or to stand up (yet neurologically normal). 

After a few days' rest in bed, he found himself able to 
walk a few steps with assistance, and was then transferred to 
the RadclifTe Infirmary for electrical treatment. This treat- 
ment consisted in electrically provoked exercises to the back 
(positive) and seat and thighs (negative). He was able to 
walk back to his ward, leaning on a wheelchair. Next day 
he walked to the electrical department with sticks, and after 
the exercises were repeated, he was found able to walk with- 
out assistance. On the third day, the Morton wave current 
was applied to the back, to clear up any persistent stiffness. 
The patient was then discharged on sick furlough. 

Re the Morton wave and similar applications of electricity, 
Zeehandelaar speaks of a high frequency hall fitted up at 
Berlin. Touching the walls of the hall with the finger elicited 
a powerful spark. The scheme appeared to be on a commer- 
cial basis, and it was proposed to start similar institutions 
for poor metabolism and neuroses in other cities. 



TREATMENT AND RESULTS 79 1 



A year's field service, gunshot; typhoid fever: 
Astasia-abasia : Lourdes-like cure: Residual 



amnesia. 



Case 569. (Voss, November, 1916.) 

A soldier in service from the outbreak of war, shot in 
September, 191 5, afterward suffering from fainting spells, 
was treated in several hospitals. He developed a typhoid 
fever at Lindau, which was at first taken for hysterical fever. 
Eventually he came to the observation of Voss, unable to 
stand and falling hysteria-wise if compelled to walk. 

Thorough examination was made. It was emphatically 
explained to him that there could be no reason why he should 
not stand or walk. 

A miracle occurred. From the second day of his hospital 
stay he not only walked about but began to polish doors and 
windows with inexhaustible strength. 

But when he was about to be told that he must now be 
looked upon as well, the miracle was not so manifest. It 
now transpired that he had serious gaps of memory and 
disorders in recognition, a sphincter disorder and ever since 
his typhoid incontinence with fluid feces. 

In short, waking suggestion had caused a very prominent 
symptom to disappear, but the total personality remained 
sick. According to Voss, the procedures of Kaufmann are 
dubious just because they cannot stand the test of time. 
Yet so far as the cure of this man's astasia-abasia was con- 
cerned, it was not at all unlike the cures wrought at Lourdes. 

Re miracles of this sort, see cases of Colin Russel (503 
and 504) as well as those of Veale (511 and 512). Voss' 
arguments run parallel with the contentions of various per- 
sons that the miracle cures (such as those by anesthesia, 
electric suggestion, and hypnosis), do not get sufficiently to 
the bottom of the affections in question. Buzzard, in the 
preface to Yealland's book on the Hysterical Disorders of 
Warfare, remarks that the question of the ultimate prognosis 
in cases thus suddenly cured must be left unanswered. 



792 TREATMENT AND RESULTS 






Dysbasia after a fall: " Kaufmann " cure in six 
weeks. 



Case 570. (Schultze, August, 191 6.) 

Severe dysbasia, due to monoplegia of the right leg of 
sudden origin (a fall), was variously treated 64 weeks with- 
out effect. 

July 15, 1916, the patient walked in on a stick, and fell 
down on trying to walk without. August 1, 191 6, at 9 
o'clock, he was rapidly examined: Anesthesia to pain and 
temperature ; inability to lift right foot ; the right knee could 
be lifted about a hand-breadth above the body if the foot 
was supported. 

At 9:10, a small electrode was applied: sensibility be- 
came normal at once. Second application: leg raised much 
better. The man was told that he was better and that his 
hand could be put under the heel. Third application: Leg 
raised 8 cm. The patient showed pleasure at the advance. 
Fourth application (slightly increased strength) : Patient 
able to stand and to lift knee with flexion at 135 while 
standing. Walking exercises under direction. At 9:30, five 
minutes recess was given for fatigue, whereupon the exer- 
cises were taken up again and transition made from station- 
ary running to walking without aid as well as a variety of 
other associated acts (grasping handkerchief instead of 
physician's hand, and the like). The patient became ex- 
hausted after 8 or 9 minutes running about, and another 
pause was given. 

The large brush electrode with stronger current was now 
given to the back and to the back of the right leg. Practice 
in slow walking, lifting knee, and holding hip joint firm. 
The patient became tired, but remained very willing. Ex- 
ercises in pulling on stockings, in climbing stairs — the 
whole concluded at 10 o'clock, whereupon it was found that 
the patient could walk alone for a distance of 50 meters. 
The patient was a very suggestible one. It was striking that 
the patient in the time between 9:35 and 9:40 minutes could 



TREATMENT AND RESULTS 793 

walk better on the right (that is, the previously affected leg)- 
than upon the left. Rest in bed and phenacetine were 
ordered, with the suggestion that in the morning he would 
walk much better. He became irritated after the treatment 
but grew quieter in the afternoon. 

On August 3, he was found able to walk well, better when 
not observed than when observed. August 5, he complained 
that his leg was worse and used a cane, without permission. 
He was roundly scolded by the physician and threatened 
with being sent to bed if he did not practice earnestly. Au- 
gust 7, he was better, and confessed that he could not walk 
as well on command as he could alone; the exercises were 
nothing but a fraud and he could go out and beat everything 
up (alles zerschlagen) if he did not have to carry out such 
exercises. 

August 15, he was much better, quiet, and satisfied. The 
lameness was practically gone. August 30, there was no 
sign of lameness, even when he was observed. According to 
Schultze, the Kaufmann method is not merely an Erb tradi- 
tion, and rather special measures need to be taken in execut- 
ing it. 

Re Kaufmann's cure, Imboden sums up this "highly logi- 
cal and brutal method" as a method in which powerful 
electric shocks and loud military orders to perform certain 
exercises secure results. Imboden suggests that relapses 
may follow, sometimes on the slightest provocation. Mann 
states that Kaufmann's method of suggestion and electric 
shock forms very good treatment; yet Mann states there 
have been two deaths under this treatment: in both in- 
stances there was an enlarged thymus at autopsy. A better 
technique, especially the use of the faradic current alone, 
might have avoided these deaths. Mann himself prefers to 
Kaufmann's Ueberrumpelung milder methods, such as rest. 
Kaufmann keeps up the sitting until the man is cured, "even 
if it takes two hours of electricity and staccato commands. 
For similar persistance, see the treatment by induced fatigue 
of Reeve (Cases 489-493), 



794 TREATMENT AND RESULTS 



Wound of shoulder: Heterosuggestion of BRA- 
CHIAL paresis. Electrical suggestion of muscu- 
lar power. Recovery in five days. 



Case 571. (Hewat, March, 1917.) 

A reenlisted soldier arrived at the Royal Victoria Hospital, 
as a case of ulnar paralysis. He had been wounded in France 
six months before by a bullet which passed through the 
fleshy part of the shoulder, above the middle third of the 
clavicle. Power in the right arm gradually diminished; 
yet two months after the wound he seemed fit enough to be 
sent to Egypt. The paresis developed, and in a month's 
time he was invalided home. He had been unable to use a 
rifle for months. 

The healed bullet wounds were found about the region of 
the brachial plexus. The patient was sure the bullet had 
damaged the nerves in that region. The right arm and hand 
were limp and over-inclined to blueness, and the muscles 
were flabby. Active movements of all sorts could be carried 
out with the arm but not against resistance. There was a 
definite anesthesia and analgesia throughout, and responses 
to touch and pain stimuli were irregular. 

By way of treatment, the patient had the muscles of the 
paretic arm stimulated electrically, and at the same time 
he was told that no nerve of the neck had been injured. He 
was greatly surprised to see his palsied arm move vigorously. 

A milk isolation treatment in bed behind screens was 
adopted, whereat the patient was angry, looking upon the 
Weir- Mitchell treatment as punishment. 

On the next day, another electrical application secured 
complete power in the arm and abolished sensory disturbance. 
Three days later the man went back to full duty. According 
to Fergus Hewat, someone doubtless had suggested to this 
patient that he had received a nerve injury. He had be- 
come obsessed thereby and developed a typical functional 
paralysis. This was a " cortical misinterpretation," which 
disappeared upon forcible demonstration of the error. 



TREATMENT AND RESULTS 795 



Exposure ; intestinal disorder in weakminded neu- 
ropath: Camptocormia and hysterical paraplegia 
Cure by psycho-electric treatment. 



Case 572. (Roussy and Lhermitte, 191 7.) 
A French territorial, 45, was observed at the Centre Neuro- 
logique, August 28, 19 16. He was a victim of hysterical 
paraplegia with tripod gait. There was a stiffness of the 
lumbar vertebral column which had lasted six months. 
This paraplegia had begun spontaneously after cold and an 
attack of diarrhoea followed by constipation. The campto- 
cormia and disorder of gait had come on gradually in the 
ambulance. He came on a stretcher. He was found to be 
able to walk with great difficulty by leaning both hands on a 
cane. The two legs were tremulous in a pseudospastic gait. 
The next day, after a single psycho-electric treatment, cure 
was complete. This patient was mentally somewhat weak 
and a constitutional neuropath. He was discharged, cured, 
October 20, 191 6. 



Brachial monoplegia, hysterical (or feigned?). 
Found able to descend ladder with arms only. 



Case 573. (Claude, July, 1916.) 

Claude had a case of a soldier with right-sided brachial 
monoplegia, which had lasted for 18 months and defied 
efforts to cure. There was a question of simulation, and 
Claude handed the case over to Vincent. 

The case came on service, June 20, and was seen June 21. 
He was then treated and found able to descend a ladder ap- 
plied to a wall with the help of his arms only. On June 24, 
he was found able to lift a weight of 10 kilos, and could now 
write with the right hand, although he had been writing 
only with his left. This man had looked like a simulator to 
many physicians. He may have been a simulator or an 
hysteric. In any case, he was cured. 



796 TREATMENT AND RESULTS 



Vicissitudes of treatment of hysterical brachial 
monoparesis (shell burial). 



Case 574. (Vincent, July, 191 7.) 

A French private was buried in a trench upon the explosion 
of a large shell, November, 19 14. He said he had had a 
11 fracture of the occiput " and had fainted away without 
regaining consciousness for several hours. 

He was evacuated to Dunkirk, then Saint Nasire, and then 
to Sables-d'Olonne. He showed no paralysis or paresis of 
limbs. During the first month, he had violent pains in the 
head, spells and vomiting. There was a slight aphasic dis- 
order. He was treated by cupping upon the head and by 
applications of ice. 

After the visit of the inspector general, he was sent to 
Nantes to be trephined. Dr. Mathieu regarded an oper- 
ation as useless. He was treated with bromides and the 
faradic current by Miraille, applied to the right arm, which 
had become paretic. 

June, 19 1 5, he started on a three-months convalescent leave 
in Paris. 

From October to December, he had electric treatment at 
the Grand- Palais. 

December, 191 5, he went to the Salpltriere under P. Marie, 
where he was given electric treatment. 

January 191 6, he went to Maison- Blanche under Laignel- 
Lavastine, where he was given electricity 4! months. 

April 4 he went back to his dep6t. 

Presented to the invaliding board, May 11, at Decize, 
he was sent to the neurological center at Bourges. He was 
there given massage and movements. Upon entrance he had 
a functional inactivity of the right arm. He should have 
been cured a long time before by the therapeutics employed. 
He was then sent to Vincent at the neurological center at 
Tours for special motor reeducation. Vincent found almost 
complete functional incapacity of the right arm, without 
atrophy, with normal reactions, no R. D., and normal ar- 



TREATMENT AND RESULTS 797 

terial pressure. June 26, 19 16, the patient was able t(0 
write, although slowly. He could sign a letter, and could 
lift a weight of 10 kilos. 

The details of Vincent's method mentioned under Case 566 
are pursued, to use his own words, with methodical ruthless- 
ness. This form of reeducation consists in maneouvres that 
make the patients yield despite themselves. The galvanic 
current is used to force a man to react voluntarily or auto- 
matically. See, for example, Claude's case of a hysterical 
brachial monoplegic (Case 574) found able to descend a 
ladder with the use of his arms only. After the physician's 
victory is secured, then a sort of consolidation must be 
obtained by means of the execution of certain movements on 
the part of the patient for an hour or two. As another 
factor in the situation set up by Clovis Vincent, is the 
enthusiasm generated in the moral atmosphere in which the 
cure takes ^place. Mott has also insisted upon this atmos- 
phere of cure, which Mott believes is in part responsible 
for the good results of Adrian and Yealland. Roussy and 
Boisseau, at Salins, started out with a process similar to that 
of Vincent, with a preliminary period of isolation. Roussy 
also uses the faradic current instead of the galvanic (see 
remarks of Mann concerning deaths with the Kaufmann 
method in Germany, under Case 570). Vincent's three 
stages are given in Chart 19, page 897. 



798 TREATMENT AND RESULTS 



Struck by shell fragment ; run over by shell ; paresis 
and regionary sense disorder. Treatment by re- 
education. 



Case 575. (Binswanger, July, 1915.) 

A German subaltern officer, 27, was wounded September 
25, 1914, in a battle in France. He gave the following ac- 
count : 

" We had been firing without interruption four days, and 
then were sent back. While going back from cover we were 
under shell fire. Three or four horses fell. I got a glancing 
blow from a shell fragment in the back of the head, and fell 
down. I was not quite unconscious. I tried several times 
to get up, but I could not, for I had very bad pains in the 
head and a confused feeling in it, too. I remember also that 
a wheel ran over my foot, and that I got a sharp blow in the 
chest. Then I was unconscious for about an hour. When 
I awoke, there were two comrades busy over me and they 
pulled me back of the firing-line. Then I got to a field 
hospital." 

The man arrived at the nerve hospital (Jena), October 8, 
1 914, with insomnia, respiratory disturbance, sudden per- 
spiration, feelings of cold in the right foot, and poor appetite. 
He had had nausea for a few days. Lungs and heart proved 
normal. X-ray of the right foot showed normal relations. 
The man was a small, powerfully-built man, well nourished, 
with lively reflexes, especially the knee reflexes, of which the 
right was greater than the left; slight patellar clonus, right; 
left plantar reflex greater than right; segmental disorder of 
touch and pain sense in the right foot and lower leg, a zone 
of analgesia lying above the zone of total anesthesia. Gait 
was lame on account of inability to move the right ankle 
joint. In walking, the right foot was trailed. 
; Treatment was suggestive and supported by active gym- 
nastic exercises, breathing exercises, exercises in moving 
the right leg, massage, faradism and local hydrotherapy. 
The gait gradually improved, the cold feeling disappeared 



TREATMENT AND RESULTS 799 

from the right leg, disturbances of pain and touch sense dis^ 
appeared. The patient was released on the 26. of February, 
19 15, capable of garrison duty. 

With respect to this man, who was married, he was from 
a healthy family and had healthy children. He is said, 
however, to have suffered from convulsions for a long time in 
early life, but thereafter had never been sick in any way. 
He was a good student and had been a post-office official 
since 1908. After two years' military service, he became, in 
1 910, Unteroffizier- Aspirant. Later he was advanced to his 
subaltern position in the reserve. 

This case seems to be a characteristic example of seg- 
mental disorder of sensations of both touch and pain, com- 
bined with a paresis in the same region. Mechanical and 
mental factors seem to have been present, and the case 
belongs in what Binswanger calls the " hysterosomatic " 
group. 

Re Binswanger's so-called hysterosomatic group, he de- 
fines the cases as having emotional, mechanical, and toxic 
(gas) factors. On the whole, they are best classified as a 
kind of psychoneurosis. Binswanger finds all physical and 
drug treatment without result except as supportives. He 
has used hydrotherapy and electrotherapy with the per- 
fectly clear conception that the procedures were of sugges- 
tive value only. In fact, Binswanger had before defined 
such procedures as Realsuggestionen or material suggestions. 
Common verbal suggestion, says Binswanger, will work some- 
times only when aided by these material suggestions. See 
also under Case 576. 



800 TREATMENT AND RESULTS 



Post-traumatic (ANTEBELLUM) seizures with un- 
consciousness : Further seizures, astasia-abasia, 
anesthesias, following no special period of stress in 
field service. Recovery by reeducation. 



Case 576. (Binswanger, July, 191 5.) 

0. F., 26, healthy, of a healthy family, in military service, 
1908-1910, a miner in October, 1912, had fallen into a shaft 
from a considerable height, and is said to have been un- 
conscious for three days and two nights and to have had some 
sort of attack a short time after waking. Later he had 
another attack, beginning with violent headaches, running 
from the back to the fore part of the head, then dizziness, 
then a fall with unconsciousness. The whole attack lasted 
about four minutes and was followed by feelings of extreme 
fatigue. 

It seems that in the spring of 191 3 these attacks had begun 
to repeat themselves two or three times a week. In the 
spring of 19 14 there had again been two attacks at an interval 
of two weeks. They had occurred on the way to work and 
had been introduced by the same symptoms as before. They 
lasted about half an hour. 

He was in the war in France from August 6, 19 14. While 
he was cooking, one day, in the middle of September, he had 
an attack and this without special occasion. The next at- 
tack occurred a little while afterwards, at the time of an 
assault. He said that he fell down and lost his senses. When 
he came to his senses again, he found he could not move his 
legs. 

He was taken to a reserve hospital in Germany, and while 
there had several attacks with unconsciousness and spas- 
modic convulsions — the last on December 7, 1914. He was 
transferred to the Jena Hospital on the nth. 

The Jena examination had the benefit of an inquiry con- 
cerning the case. It seems that he had left the field hos- 
pital in the enemy's country, in a half-conscious condition, 
and rode away therefrom aimlessly. It was only in Ger- 



TREATMENT AND RESULTS 801 

many that he, on his own story, found his bearings agaim_ 
However, upon admission the disturbance in walking was very 
noticeable, since the patient came hobbling through the 
garden of the clinic with the upper part of his body bent 
forward, and with the support of two canes. The legs were 
moved with difficulty; he seemed to take short, tripping 
steps, with the toes dragging on the ground. His inability 
to walk he explained through the violent pains which he 
would feel in the joints of the legs and an extraordinary 
weakness in his legs. 

Physically, the man was a tall, strongly built and well- 
nourished subject. Neurologically, the knee-jerks were some- 
what decreased and weaker on the right side than on the left ; 
the Achilles reflexes were lively. The plantar reflex was not 
obtainable on the left side; decreased on the right. The 
abdominal reflexes were absent on both sides. 

Most remarkable was the general diminution in sensi- 
tiveness of the skin to touch and pain, involving the whole 
body, up to the neck, where the sensory impairment abruptly 
ceased in a sharp line. The anesthesia was not everywhere 
complete. In a few places pencil strokes were successfully 
localized and recognized. Deep pin-pricks were everywhere 
recognized as itching. When the trunk was everywhere 
examined on both sides symmetrically, a strong pressure with 
a pin-head was felt as a strong pressure on the right side, but 
was felt not at all on the left side. Anesthesia and analgesia 
were total in the legs. Deep folds of skin could be punctured 
by needles without reaction. 

The legs could be moved freely upon urgent request with 
the patient in dorsal decubitus. Still these movements were 
slow and difficult, as explained by the patient, on account of 
violent pains in the joints. If put on his feet, he would begin 
to sway greatly and permit himself to slide down to the ground, 
stating that he was quite incapable of standing or walking 
without aid. With two canes, however, he could move freely 
about in the ward and in the garden, and even with consider- 
able speed, in a peculiar, dragging, shuffling way; in the 
execution he gave no sign of pain, contentedly smoking a 
cigar or a pipe. 



802 TREATMENT AND RESULTS 

While his status was being taken on admission, he became 
suddenly dull and irresponsive, with a staring look. He 
could not state his age or his birthplace. However, he be- 
came clear shortly, upon urging, and explained the spell by 
saying that the blood had risen to his head. A few days later, 
he was transferred to the psychiatric division. He was 
given strict rest in bed, smoking was forbidden, prolonged 
baths were used, and the legs were massaged. He felt very 
comfortable in the prolonged baths and could then move his 
legs without pain. 

A few days later he was taken out of bed several times a 
day, the canes being removed immediately, and he was led 
about the day-room with the light support of two nurses. 
Being promised a cigar as a reward, he proved able to walk 
through the day-room supported by but one nurse. A week 
later the pains in walking exercises had disappeared. He had 
become able to walk alone, supporting himself lightly along 
the wall with one hand. Walking was still uncertain and slow. 

December 20, the patient could stand free without sup- 
port, swaying slightly; improvement became rapid. He 
could shortly stand and walk without support though his 
walk was still awkward and on a wide base with knees pressed 
in and body bent forward, soles were kept applied to the 
ground. December 22, the patient could walk in the garden 
without aid. 

December 23, there was a spell of great weariness and 
complaint of being sick. The patient lay down on the bed, 
cried aloud, and had rhythmic twitchings and sudden move- 
ments with arms and legs. He scratched the right half of his 
face with his right hand. This spell lasted about a minute. 
It was repeated in the same way twice within the half hour. 

He had complete amnesia for these attacks. The pupil- 
lary reactions were entirely normal in the attacks. He had 
been in bad spirits that day because a Christmas furlough 
had been refused. The attacks provoked no bad conse- 
quences and his gait improved. He was on furlough from 
the 30th to January 3 ; on the 4th he was transferred to the 
nerve department, but on the 12th of January he was repri- 
manded for a breach of discipline, whereupon at 9: 15 he had 



TREATMENT AND RESULTS 803 

an hysterical attack with the same coordinate and rhythmic - 
motions as before. This attack lasted about 20 minutes. 
Two hours before the attack he had complained of weariness 
and a boiling-hot feeling in the body. Long walks were 
taken. On February 15 he began to feel very happy. He 
was informed that the charge against him for leaving his 
troop had been dropped. He complained of sudden weariness 
and headache and was markedly depressed, but he had no 
hysterical attack. 

After February 23 he took part regularly in gymnastics, 
executing the movements with joy and without special wear- 
iness. He wanted to be discharged. He was discharged as 
fit for garrison duty and he has since gone back to field ser- 
vice. 

Re gymnastics, Binswanger holds that they have a special 
value in overcoming inner psychic resistances and weak- 
willed persons. The Realsuggestionen (see under preceding 
case, 575), such as hydrotherapy and electrotherapy, serve 
to concentrate the person's attention on certain regions. 
These regional suggestions then smooth the way for the 
curative suggestion, namely, the constant and monotonously 
repeated assurance that recovery is advancing. At the next 
stage, according to Binswanger, gymnastic exercises may be 
brought in to overcome hopelessness, indifference, or exag- 
geration of morbid feelings. Binswanger sets methodical 
tasks for the attention and the will (a so-called Uebungs- 
therapie). If these gymnastics lead to manifest improve- 
ment, then a proper educational therapy is prescribed, which 
is no longer a merely exercise therapy, but consists of 
actions of actual value in hospital routine. The convales- 
cents are gradually led to carry on housework, food service, 
gardening (the latter under supervision). Hospital clerical 
work is a suitable occupation. Re supervision over garden- 
ing, mentioned by Binswanger, Canadian experience indi- 
cates that the idea of supervision may be greatly extended. 
Particularly is this true in vocational reeducation. Kidner 
describes the functions of a vocational counsellor, who has 
to have an expert knowledge of industry and methods of 
industrial training, as well as an acquaintance with the vary- 



804 TREATMENT AND RESULTS 

ing demands for workers, a knowledge of the seasonal varia- 
tions in employment, and a knowledge of occupational dis- 
eases. Re occupational therapy, Todd estimates that from 
0.5 to 1 per cent of wounded men in France will require 
vocational reeducation. Occupational therapy is the proper 
vestibule to vocational training. He lists the following 
forms of treatment used in institutions for vocational reedu- 
cation : 

Active mechanotherapy. 

Passive mechanotherapy. 

Galvanic, static, and faradic electricity. 

Vibration. 

Hot air baths and blasts. 

Water baths. 

Colored light. 

Massage. 

Gymnastics. 
Central specialized institutions such as those developed 
in France are necessary, and such centres should be large 
rather than small, according to Todd, and should contain 
not less than 200 beds. Todd insists that work is, after 
all, the most important measure of reeducation; and Turner, 
speaking of the home for neurasthenics at Golders Green, 
says that during a period of three months (the number of 
the patients is limited to 100, and three months is the limit 
of stay), the vast majority, even of the most obstinate 
cases, get well through the effects of sympathy and insist- 
ance upon work. Near Golders Green is the Maida Vale 
Hospital for nervous cases, so that in case of need the phy- 
sicians there may treat the patients. Salmon gives a list 
of the occupations which are suitable for these cases. 



TREATMENT AND RESULTS 805 



Blown up by shell; wounds, right side, distention 
and bloody urine : Paresis of right foot and spastic- 
ity of hip ; later rectal and bladder incontinence. 



Case 577. (Binswanger, July, 1915.) 

A Russian from the Ukraine was received at the nerve 
hospital, Jena, December 12, 19 14. Through an interpreter 
it was established that he was a peasant, had been under 
shell fire in a skirmish at the beginning of November, and 
had been hurled (so he said) i^ meters into the air without 
loss of consciousness. There was a wound of the right 
shoulder and also, he thought, of the legs, from the air pres- 
sure. Becoming a German prisoner, he had been treated in 
various hospitals. 

He was a strong man of medium height, with a healthy 
complexion. There were two healed wounds of the right 
shoulder, and near the twelfth spinous process a third similar 
scar. There were a number of ulcers and furuncles over the 
os sacrum. 

Neurologically, the knee-jerks and Achilles jerks could not 
be obtained, and the plantar reflex, extinct on the left, was 
weak on the right. Sensitiveness to pain on both sides was 
lost from the knee downwards but there was hyperalgesia in 
the thigh. Inaccurate statements in response to tactile tests 
were made, apparently on account of lack of understanding. 
In lying down, there was a slight restriction in the move- 
ments of the legs, and active movements of the joints of the 
foot on the right side were 'mpossible. Gait was ataxic- 
paretic, more markedly so right than left. He could walk 
only with two canes, and during walking the musculature of 
the thigh fell into a spastic tension. The tongue deviated 
to the left. There were severe rheumatic pains in the thighs. 

It appears that some weeks before, this Russian soldier 
had suffered from severe rheumatic pains in both sides and 
was at that time absolutely unable to walk or stand. At 
that time, however, there was no question of a crural para- 
plegia of organic origin, since the man could move his legs 



So6 TREATMENT AND RESULTS 

well enough when in dorsal decubitus. There were no signs 
of paralysis of the rectum or bladder at that time. 

Treatment at Jena consisted in regular walking exercises 
with support at the shoulders. The lower legs and feet re- 
mained weak and paretic. The decubital ulcers disappeared. 

About the middle of December rectal incontinence began, 
the stool being discharged without the patient's noticing it 
while being led to the bath. Later there was incontinence 
of feces in bed. Pains in the legs were constantly com- 
plained of. Nevertheless improvement in walking was main- 
tained. The toes were dragged at every step and the knee- 
joints were thrown outward in walking. The musculature of 
the lower legs was weak. Knee-jerks could not be elicited 
more than before. He constantly complained of pains in the 
knees and right hip. The rectal disorder did not again 
occur during January. 

Toward the close of January, the patient's right lower leg 
and left foot would occasionally feel asleep; both legs felt 
cold and itched. In a general way, however, the pains had 
become less marked than they were at first. It seemed that 
he had no sensations at stool, and consequently had to re- 
sort to the closet at a definite time. Moreover, urine was 
discharged irregularly and involuntarily when he coughed. 
It appears that a few days after receiving his wounds in 
battle, there had been pains on micturition as well as blood 
in the urine, and it appears that he had been catheterized. 
It is probable that he had suffered from distention, as he 
described his abdomen, thighs and sex organs as swollen. 

In February he began to be able to move alone with two 
canes through the ward, but he moved his legs from the 
knee downward very little, and dragged them after the rest 
of the body. Upon galvanic examination, the peroneal and 
tibial nerve trunks were found normally excitable. At this 
time the sensibility situation had changed somewhat, since 
complete analgesia was present only in the foot, and hypal- 
gesia had developed upon the anterior surfaces of the lower 
legs. Pin-pricks were described as touches. The posterior 
surface of the left lower leg was normally sensitive. There 
was an oblong stripe about 3 cm. long, beginning in the pop- 



TREATMENT AND RESULTS 807 

liteal space and stretching downward on the left side. The, 
right lower leg was entirely insensitive. The posterior sur- 
faces of both thighs as far as the gluteal folds were com- 
pletely insensible to pain. The Wassermann reaction of the 
blood was negative. In this condition the patient was trans- 
ferred to a prison camp hospital. 

Re bloody urine, see Section B, Case 202. Re rectal in- 
continence, it might be inquired whether this was possibly 
functional. Roussy and Lhermitte devote a chapter to vis- 
ceral disorders. They do not list rectal incontinence amongst 
the disorders noted in this war, nor have any cases of hys- 
terical anorexia or disorders of sensation in the intestinal 
tract been seen during the war despite the occurrence of 
these latter disorders in the civilian group. The main diges- 
tive disorder that the war cases show is vomiting (see 
Cases 495 and 500). 



808 TREATMENT AND RESULTS 



Emotionality : Shell explosion ; mutism. Recovery 
by reeducation. 



Case 578. (Briand and Philippe, September, 1916.) 

A plumber, 27, went into the infantry. He was very 
emotional and was but a short time in the trenches when the 
explosion of shells threw him into a state of mutism. Deaf- 
ness, rather curiously, did not manifest itself for several 
days. He had to go back on horseback, and, as he was a 
poor horseman, slipped off the horse, giving himself a bad 
fright. When he got up, he had lost his hearing. 

He was sent to several hospitals and finally to Val- de- 
Grace, in July, 1915. He recovered hearing in fifteen days, 
but the mutism persisted several months. According to 
Briand and Philippe, this is a typical case, except for the 
duration of the mutism. The first treatment was given this 
patient August 6. His respiration was examined and tracing 
was taken. August 15, on the morning visit, he was found 
able to whistle very distinctly the first bars of "Au Clair de 
la Lune," and then began to sing the first verses, articulating 
distinctly, but stammering a little. He was now left to his 
own resources, without special exercises, from August 15 to 
September 26, and completely lost the benefit of his previous 
exercises. A week of special treatment allowed him to re- 
cover speech again, enough to take up every day life. The 
patient went out well. 

The general lines of the examination in this case took up 
attitude in abdomina respiration and the question of respira- 
tory pauses, especially pauses in abdominal respiration, 
which, in the above case, were exaggerated. Expiration 
was deficient and disordered. The normal adaptations that 
had been established during his childhood learning of speech 
had failed, and the patient would not have been able by 
himself to regain proper balance of respiration for speech. 

The examination was continued to learn the difficulties of 
innervation of the muscles of phonation whose proper deli- 
cacy had been lost. Such a patient is a kind of bad gym- 



TREATMENT AND RESULTS 809 

nast, executing an exercise known to be hard by contracting 
all the muscles of the region, both the antagonist and the 
agonist muscles. Reeducation must, therefore, endeavor to 
sweep away the contractions that block sound. Then the 
patient must be made to perform the contractions necessary 
in phonation and articulation unconsciously. The methods 
used for teaching children might here be employed, but 
more elaborate and designed methods can be used with the 
adult, e.g, 

1. Breathing exercises, especially with the idea of making 

respiration complete. 

2. Blowing exercises. 

3. Whistling. 

4. Vowel sounding. 

Seguin and Rouma, on the other hand, counsel beginning 
exercises with consonants in stammerers and dyslalics. 

Re tests for functional deafness, Ranjard states that on 
account of the complexity of Shell-shock deafness, exact 
diagnosis needs to be made. Examination of the hearing 
by speech alone, or by the watch-tick, yielded poor results; 
and an accurate mathematical acoumeter (Sirene a voyelles, 
Marage) is recommended. See especially chapter on the 
functional examination of audition in Bourgeois and Sour- 
dille's War Otitis and War Deafness, a work translated and 
highly recommended by the English otologist, Dundas 
Grant. 



8lO TREATMENT AND RESULTS 



Three days' skirmish on East front : Unconscious- 
ness, later delirium, still later (six weeks) stammer- 
ing, hysterical stigmata : Recovery by isolation and 
reeducation. 



Case 579. (Binswanger, July, 1915.) 

A traveling salesman in civil life, 36, as a non-commis- 
sioned officer took part in severe fighting in the East shortly 
after the outbreak of the war. He was under violent shell 
fire at one time for five hours at a stretch. In the middle 
of November, after a skirmish in the woods which had lasted 
for three days, he was found unconscious. According to his 
own story, he was awakened from this unconsciousness about 
a week later in a hospital. He described himself as quite 
unable to say anything about what had gone on during that 
week. 

The medical report on the case stated that he arrived at 
the hospital, November 18, in a dormant state of mind. He 
had appeared markedly excited and kept incessantly talking 
about military matters, such as the placing of machine guns, 
the occupation of the edge of the woods by his company, 
addressing the nurse as "Captain," and the sister as "Mrs. 
Captain," making as it were an official report to them. He 
showed shyness, and always an extreme excitement. His 
hands and legs were in constant motion; he complained of 
headaches and itching finger-tips. Sleep could be achieved 
only by drugs. This mental state lasted till November 26, 
when he became oriented. Sleep improved, but he com- 
plained of pains in the back of the head. 

Upon transfer to a convalescent home, December 5, he 
was still occasionally excited and sometimes sleepless. On 
December 30, the patient began to stammer; his speech had 
before this been somewhat difficult, but the stammering be- 
gan suddenly; speech was indistinct and slow; syllables 
failed to follow one another at like intervals. The head- 
ache at this time radiated from the middle of the top of the 
head to the side of the neck. There was a complaint of 



TREATMENT AND RESULTS 8 1. 1 

vibrating pains on the two sides of the vertebral column, and 
a feeling of weakness and unsteadiness in walking. The- 
patient would sway with eyes closed and turn side wise. The 
heart action was tumultuous, the pulse irregular and uneven. 

The patient was transferred back to the reserve hospital 
on January 2, 19 15, whereupon the stammering became worse, 
sleep restless, and arms and legs subject to spasmodic pains 
and twitching. On January 25, he was removed to the Jena 
Hospital. He remarked that at the convalescent home he 
became very much excited at the Christmas celebration and 
had to cry, whereupon his speech became more and more 
difficult ; he could not find the beginnings of words and had 
to stammer. Upon admission he also complained of sharp 
pains in the soles of the feet and in the finger-tips. 

Neurologically, there was marked dermatographia, the 
deep reflexes were increased, abdominal reflexes were absent; 
there were points of pain on pressure in both supra-orbital 
regions, and there was a general hypalgesia with the excep- 
tion of the head, the lower legs, the feet, the scrotum, the 
penis and the anal region. Pin-pricks were recognized on 
the right side only, when the patient was tested bilaterally. 
They could be recognized on both sides when the patient was 
examined on one side at a time. There was a static tremor 
on both sides (?). He could move his arms, but in dorsal 
decubitus he could move his legs only jerkily and uncertainly. 
His gait was waddling with dragging of toes. 

There was a marked photophobia. The palatal and swal- 
lowing reflexes were in excess; speech was hesitant and 
stammering. The first letters of words, especially initial 
consonants, could be pronounced with difficulty, explosively 
with cheeks blown up, after several attempts. The conso- 
nant would be repeated several times before the vowel could be 
added. The patient's name was Singer, and he would pro- 
nounce it : S . . . S . . . S . . . Si . . . n . . . n . . .ger; 
the last syllable {ger) being brought out with a strong accen- 
tuation. The whole process took five seconds. The word 
Flanelllatten took 14 seconds. It seems that the patient had 
already suffered (in 1907) from nasal catarrh and disturbance 
of hearing from stoppage of the Eustachian tubes. Another 



8l2 TREATMENT AND RESULTS 

attack in 1908 had been accompanied by an irritating cough, 
and there seems to have been catarrh on the right in 1913, 
as well as cerumen on the left side. 

Treatment: The patient was isolated; in the next few 
days there was improvement in the headache. The patient 
complained of muscular twitchings, which would occur sud- 
denly in different parts of the body. On February 1 there 
was a subjective feeling of happiness since all pains had dis- 
appeared. 

The patient was given regular exercises in speaking and 
there was gradual improvement in speech. Body-weight in- 
creased, regular walks were taken, and the patient occupied 
himself with garden work. 

By June, 191 5, he had still further remarkably improved, 
working now all day long, partly in the garden, partly in the 
hospital office. Disturbance of speech was not noticed ex- 
cept for hesitation before the last syllables of long words dur- 
ing comparatively long conversations. All trace of difficulty 
in walking had disappeared. In this patient no hereditary 
taint could be proved. He appears to have been of normal 
development, serving in the army from 1901 to 1903. In his 
life as a traveling salesman, there was frequently catarrh of 
the throat, and in 191 2 there was a marked swelling of the 
vocal cords with extreme hoarseness and inability to speak, 
which condition was cured after local treatment. 

Re hysterical speech and voice disorders, Binswanger has 
found them amongst the most obstinate conditions, often 
persisting when all other hysterical phenomena have dropped 
away. He states that apparently the cure of some of these 
cases must be postponed until the end of the war. 

Re general results of the therapeutic treatment of the war 
hysterias, Binswanger states that he has been able to send 
some cases back to the front that have successfully stayed 
there. He has had failures, however, even amongst men 
who have had no mauvaise volonte and have themselves 
desired to be sent back to the front. 

Gordon Wilson observed 250 cases of Shell-shock at the 
Ypres salient and on the Somme. Fifty of these cases 
complained of deafness, and 17 of the 50 were found to have 



TREATMENT AND RESULTS 813 

actual nerve deafness. Wilson treated " fixed idea" cases, 
by hypnotism, and sometimes by cold water run into the 
ear. He, in general, divides the cases in to (a) cases of 
nerve deafness, (b) fixed idea cases, and (c) malingerers. 

Marage states that frequent exposure to the noise of 
shells for long periods may produce a permanent deafness, 
as has long been known in naval gun-makers and boiler- 
makers in peace times. He advocates obturators, a good 
form being plasticine wrapped in gauze moulded to the 
shape of the internal meatus. Celluloid plugs, sometimes 
used, have been known to be set afire by the flash of a shell. 
Cerumen sometimes protects against deafness, but Mott 
speaks of the driving of the wax into the tympanum as a 
dangerous effect in certain shock cases. 



8 14 TREATMENT AND RESULTS 



BURIAL by shell explosion: DEAFMUTISM. 
Treatment : phonetic reeducation. 



Case 580. (Liebault, 1916.) 

A machine gunner, 26, was buried at Rheims, January 5, 
I9 X 5> by the explosion of a large shell bursting over the 
dugout. He was unconscious three days and deafmute on 
coming to, without amnesia but with a feeling of constric- 
tion in the throat. 

After fifteen days in the ambulance he was sent for four 
months to the Maritime Hospital at Brest, and treated by 
hypnotism. Seven or eight sittings had no other result than 
to fatigue him. There were then three months of conva- 
lescence. Returned to Vannes, September 20, 191 6, he was 
put into the auxiliaries. As he could not work much he 
was sent, December, 191 5, to the Hotel- Dieu at Nantes. 
Here electric vibratory massage was given, which secured a 
few hoarse sounds. 

Phonetic reeducation was then undertaken at Pres-a- 
goutriere, May 10, and his respiratory capacity increased 
from 170 the first week to 250 and 300 the following weeks. 
His blowing strength was raised from 15 to 20 to 25 at the 
same time. In a few weeks he was much improved and 
June 27 passed on to his auditory reeducation. The res- 
piratory capacity in this man was insufficient. He could 
not speak, but his respiratory movements were good and he 
learned again to speak in a voice as good as ever. 

According to Liebault, it is a general principle that, if 
the respiratory capacity is increased, the voice will clear or 
become better; but, if the respiratory capacity remains 
stationary, the voice will not improve. It is the same with 
normal persons. A subject with a very subnormal respira- 
tory capacity cannot speak loudly, but, if his respiratory 
capacity approaches normal, he can speak normally. Ac- 
cording .to^ Liebault, all cases! of this sort have had some 
respiratory anomaly and each case must be systematically 
examined with the aid of anthropometric f tables, including 



TREATMENT AND RESULTS 815 

weight, height and chest capacity. The vocal disorder is 
proportionate to the degree of functioning of the phonating 
apparatus taken as a whole. It is not merely that the 
larynx should be examined, but the motor side of the appa- 
ratus, the respiratory muscles, the resonating apparatus, the 
lips, the mouth, the nasal fossae and the pharynx. 

Re curability of different types of war deafmute, Roussy 
and Boisseau maintain that the type (a) that comes ges- 
ticulating, pointing to the ears, and desirous of writing, is 
the type that responds most rapidly to psychotherapy. 
There are two other types less responsive: (b) is an apa- 
thetic type, with impassive and stupid facies, lies immobile 
in bed, or sits in a chair in mental confusion; type (c) shows 
a facies of terror, looks haggard and anxious, confused, dis- 
oriented, and possibly delirious. 

Re general treatment of deaf cases, Zange suggests that 
emotion should not be aroused by intense auditory impres- 
sions, that he should not be reminded of his shock, and 
should be kept as cheerful as possible. Zange states that 
he found the static electric current of service, and got good 
results in hysterical deafness of sudden development by 
applying a strong faradic current. 



8l6 TREATMENT AND RESULTS 



A year's service; leave: Hysterical aphonia de- 
veloped at home. Respiratory gymnastics. 



Case 581. (Garel, April, 191 6.) 

A soldier, 35, went on leave August, 191 5. Arriving at his 
farm, he had a violent feeling of moral perturbation and sud- 
denly lost his voice. When he returned from leave he 
seemed stupid, spoke very few words and seemed to look 
about in a vague and undecided way. He was several 
months in this state and sent January, 1916, to Saint-Luc. 

The vocal cords were there found of a normal color and 
without paralysis. "It was, therefore," remarks Garel, "a 
nervous aphonia susceptible of instantaneous cure." The 
patient was made to make a sound in the lowest tone pos- 
sible. While he was making this attempt, sharp pressure 
was exerted upon the lower part of the sternum, to provoke 
expiratory reinforcement. The sound emitted was loud, to 
the great astonishment of the patient, who, thus aided by 
suggestion, shortly began to talk aloud. 

In this particular patient a temporary return of voice was 
readily obtained, but not maintained. Special exercises had 
to be instituted, whereupon the patient immediately fell 
back into a complete aphonia. He was then made to scan 
words, syllable by syllable, executing with his arms classical 
movements of respiratory gymnastics, or sometimes with 
the utterance of every syllable the epigastrium was manually 
compressed or the shoulders suddenly lowered. The patient 
could now read a book in a jerky manner, and after a few 
lines he could read without his shoulders being pressed. 

Another plan was to have the man read or talk while 
walking. As soon as he was stopped and accosted, however, 
he lost his voice again. Up to the time of report it was 
impossible to secure a definite return of voice, as the patient 
was not willing to associate words with peculiar movements. 
It might make him ridiculous. Accordingly, the nurses were 
requested not to fulfil requests unless they were made aloud. 
Recovery was to be hoped for from this measure. 



TREATMENT AND RESULTS 817 



Wounded: Recurrent stammering: Reeducation. 



Case 582. (MacMahon, August, 191 7.) 

A young English officer, previously cured of stammering 
while a boy, fell to stammering again after being twice 
wounded. The impediment was of the laryngeal type. 
When spoken to he was often quite speechless. In Shell- 
shock stammering, the chief difficulty according to Mac- 
Mahon is in the production of voice consonants and vowel 
sounds. In mild cases the trouble is best left alone. 

This officer was anxious to pass into the regular army from 
the reserve to which he was attached. The stammering 
prevented this. He was treated nine months and improved 
rapidly. He passed through the trying ordeal of the medical 
board successfully and went to his regiment. 

In severe cases the patient is taught how to fill his lungs 
properly. He is taught to acquire an inferior lateral costal 
expansion in inspiration. During expiration the abdominal 
muscles are trained to contract slowly and strongly, pressing 
the diaphragm upwards and drawing the lower ribs down- 
wards and inwards. This steady breathing produces a sen- 
sation of repose in the stammerer. He is not to raise the 
upper chest and not to tense the throat, tongue or jaws. 

The main vowel sounds are now taught. The main vowel 
sounds are 00, oh, au, ah, a and ee. They combine in six ways, 
oh and 00 in the word wound, ah and ee make the long i, 
au and ee in boy, oh and 00 in road, a and ee in rain and fair, 
ee and 00 in new and you. There are also words in which 
no main vowel or compound sounds appear, which may be 
placed either on the open ah position or the closed ee position. 
Such words as long, abbot, among, which are on the position 
of ah and such words as it, sister, minister which are in the 
position of ee. The voice consonants are b, d, g, j, 1, m, n, r, 
v, w, y, z, w, w being 00 sound and y the ee sound. The 
breathed consonants are c, f, h, k, p, q, s, t. 

The treatment of stammering intensified by Shell-shock 
is more difficult than that of Shell-shock stammering de novo. 



8l8 TREATMENT AND RESULTS 



Wound of face: Speech disorder. Recovery by 
reeducation in two months. 



Case 583. (MacMahon, August, 1917.) 

An officer was wounded under his left eye, October 7, 191 6. 
His speech was affected only five days later in a casualty 
clearing station. Observed by MacMahon, November 5, he 
was found to speak with great difficulty and became ex- 
hausted after a few words. He was tensing all the muscles 
in attempting to speak. Breathing advice was given and 
counsel how to relax in the abnormal efforts. 

November 12, the officer, who was at Number One London 
General Hospital, began to speak with more freedom. "I 
am getting a bit better. I feel I must keep quiet, and it 
comes after a bit. I think far quicker than I speak." He 
said that the breathing exercises had helped him most. 

November 15, he still spoke in a rather staccato way; but 
the words did not check as they had. In a week further 
there had been so much improvement that he was discharged 
with a prognosis of complete recovery. 

January, 191 7, he had recovered. 



TREATMENT AND RESULTS 819 



Shell wound and burial : Camptocormia (psycho- 
electric treatment successful in one seance) and 
lameness (long reeducative treatment successful). 



Case 584. (Roussy and Lhermitte, 191 7.) 

At a Neuropsychiatric Center, September 2, 19 16, arrived 
a chasseur, 29, showing lameness of a pseudocoxalgic type on 
the left side, combined with an anterior camptocormia. The 
whole situation had lasted a year. The chasseur had been 
wounded by shell explosion on the left side and was buried 
on July 29, 19 15. He lost consciousness and had respira- 
tory trouble and mutism. His arched walk and lameness 
began August 20, 191 5. 

He had a number of terms in hospital and six months at 
the depot. He was sent back to the front, June 20, 1916, 
being proposed for auxiliary work. There was some mental 
weakness. After one seance of electric treatment, the im- 
proper attitude of the trunk was corrected. The lameness, 
however, persisted and required long daily reeducation. 

The patient was discharged cured, October 20, 19 16, with- 
out lameness or camptocormia. There were a few persis- 
tent lumbar pains. 

Re treatment of war psychoneuroses, Roussy and Lher- 
mitte recommend rational and persuasive psychotherapy 
after the manner of Dejerine, Dubois, Babinski, and others. 
Hypnosis, they say, should definitely be rejected. Mental 
contagion must be staved off, and Roussy and Lhermitte 
believe that almost all cases are curable and should be sent 
back as competents. 

They maintain that the medical officer himself plays the 
leading part. Many patients are ''cured" when they find 
"good masters"; this mastery of the combined confessor 
and educator is greatly aided by prestige. He must speak 
with authority, with "iron in the velvet glove"; but with 
patience and persistence. If a long sitting fails, postpone 
work on the pretext of resting the patient. The patient 
must not be early threatened with discipline. Even exag- 



820 TREATMENT AND RESULTS 

gerators and malingerers must be talked to as if neuro- 
pathic. 

A careful medical examination, besides correcting false 
diagnoses and demonstrating hystero-organic associations, will 
give the patient confidence in his physician. 

A new patient is more easily cured than an old one. In 
general, patients should be treated as soon as possible after 
the shock. Contractures are habitually more persistent 
than paralysis; tremors and tic are more pertinacious than 
deaf mutism; ante-bellum psychoneuroses are less easy to 
treat than cases developed by the war alone. 

The neurological centers near the front, with their disci- 
pline, inaccessibility to friends, and nearness to the front, 
present a situation which yields easier and quicker cures 
than the interior; but after the two-years' experience which 
proved this fact, according to Roussy and Lhermitte, many 
cases still get sent back into the interior for many months, 
— cases that ought to be cured near the front. Cases hav- 
ing convulsive attacks get confinement in separate rooms; 
chronic neuropaths are kept in bed on a milk diet. 

The general features of the treatment of psychoneuroses 
commended by Roussy and Lhermitte are summed up in 
what they call the psychoelectric and reeducative method, 
divided into four stages: A stage (a) of persuasive conver- 
sation ; (b) isolation ; (c) faradization ; and (d) physical and 
psychical reeducation. Roussy and Lhermitte got during 
six months in one of the army neurological centers, 98 to 99 
per cent of recoveries. Clovis Vincent, in a special interior 
hospital (see for Clovis Vincent's treatment, a summary 
under Case 575). Re the first stage of persuasive conversa- 
tions, Roussy and Lhermitte discuss on the day of admission 
the general nature of the patient's condition, and place him 
in the atmosphere of cure, in contact with recovered patients. 
The conversation takes place in the physician's consulting 
room. The patient is gotten to promise on oath that he 
will submit to any methods of treatment. Although one 
may pass from the first stage to the third or electrical stage, 
forthwith, Roussy and Lhermitte recommend several days of 
isolation. The patient is placed in a separate room, and 



TREATMENT AND RESULTS 821 

kept in bed on a milk diet. This isolation treatment "of 
Weir Mitchell allows reinforcement of the suggestion by 
talks on the medical rounds, allows the patient, perhaps, to 
beg for the electrical treatment, which he may have refused 
at first, and lengthens the period of observation. According 
to Roussy and Lhermitte, spontaneous recovery not infre- 
quently takes place during this phase of isolation. Lame- 
ness of long standing, tremors, and deafmutism disappear. 

The third stage is that of faradization, executed by the 
physician with only such attendants as may be necessary 
to support the patient. At first, the man lies nude upon 
the bed, but later may be treated while sitting, standing, 
walking, or running. Feeble currents are used at first; 
later stronger ones. The poles are applied to the affected 
parts, and sometimes to especially sensitive parts of the 
skin, such as the ears, neck, lips, soles, perineum, and scro- 
tum. Energetic treatment by the rapid method is indi- 
cated in the vast majority of cases, especially at the front. 
If a case is seen early, the rapid energetic treatment almost 
always cures at once. The success of the method depends 
upon the production of a crisis, which ought to be produced 
at the first sitting. Sometimes this sitting has to be con- 
tinued for hours. Some patients require two or three sit- 
tings; some, still more. Instead of faradism, a cold jet of 
water, or even painful subcutaneous injections of ether, may 
be used. 

The fourth stage is that of physical and psychical re- 
education, important in long-standing cases. The various 
forms of physiotherapy are carried out by special assistants 
or head nurses, accompanied by psychotherapy, and if nec- 
essary by electricity. According to Roussy and Lhermitte, 
these reeducative methods used alone, without previous 
faradic treatment, are not successful. Relapse follows 
premature transference from the front to hospitals in the 
interior, and too early sick leave. 



822 TREATMENT AND RESULTS 



Shell-shock deafmutism. Speech recovered by 
suggestion and reeducation; hearing by reeduca- 
tion. 



Case 585. (Liebault, October, 1916.) 

A corporal, 20, was exposed to the shock of an aerial 
torpedo, January 18, 19 16, at Souchez. The torpedo fell a 
meter away. There was no loss of consciousness, but the 
patient was agitated for several hours, not knowing what he 
was doing. Evacuated to hospital, he remained several 
days in a stupid state. He was completely deaf and remem- 
bered poorly what had happened. He made every effort to 
speak, but could not. His head felt on fire. He could not 
open his mouth well and his lower jaw was almost in a state 
of contracture. He felt that his tongue could not move 
easily. In this status he remained until February, always 
trying to talk, but not succeeding. 

He then arrived at Hotel- Dieu. The mouth was now 
opening better and he was in a better general status, though 
always feeling fatigued. Vibratory massage was given to 
the laryngeal region. He was gradually got to emit a few 
sounds in a low voice. He was sent, April 26, to Pres-a- 
goutriere. He was now somewhat vocal, but at times would 
become completely aphonic once more. The voice during 
the first few weeks of treatment became better, and the 
respiratory capacity was increased from 450 the first week to 
460 and 500 in the next two weeks. 

May 12, he suddenly lost his voice again and wanted to 
commit suicide. However, in three more days he was able 
to speak normally again and has had no relapse. He was 
then put under auditory reeducation and at the time of 
report his hearing had slightly improved. 

Liebault remarks that during the time when the patient 
could not speak his jaw muscles were contracted and his 
tongue could not mobilize well. He could think words but 
could not articulate them. It was accordingly important to 
cultivate the normal functioning of these muscles. 



TREATMENT AND RESULTS 823 



T 

Gassing; tracheitis; crash from airplane; un- 
consciousness: mutism; stammering. Reeduca- 
tion; hypnosis. 



Case 586. (MacCurdy, July, 1917.) 

A lieutenant in the Royal Flying Corps, 23, described as 
" unusually normal," a successful business man, athletic, 
socially popular, had been for a year in the Infantry. He 
was caught suddenly in a gas attack, and, though he re- 
covered after a few days in bed, had a severe tracheitis and 
laryngitis. The lieutenant had been very proud of his voice 
and its carrying power. He went to a laryngologist in Lon- 
don, who said that he would never be able to sing again — a 
matter of some worry. 

He soon became an expert airman. In the spring of 191 7 
he was shot at by antiaircraft guns in a trip over the enemy's 
lines. One of the wings was hit and so weakened that in 
landing the lieutenant crashed to the ground. He was un- 
conscious for three hours and on coming to tried to shout to 
his servant in the distance, who, on arrival, found the lieu- 
tenant quite unable to speak. 

According to MacCurdy, there was here a conversion hys- 
teria with regression to the tracheitis that followed the gas- 
sing. The mutism MacCurdy regards as a pathological de- 
gree of an effort of protection for his voice. In hospital 
three weeks later he learned to whisper a few words, though 
with great mental effort. He regained the voiced sounds by 
coughing and then saying "ah." Stammering now devel- 
oped. Not more than one or two words could be said at a 
breath. Training to say two, three, four and then five letters 
in one expiration yielded improvement in the stammering. 
Under mild hypnosis, to the degree merely of distraction, 
normal speech was re-attained. There was no relapse. 
Singing was then^practiced and in a period of six weeks the 
singing voice was virtually as good as it ever had been. 



824 TREATMENT AND RESULTS 



Shell-shock : Loss of consciousness, possibly hem- 
orrhage from head : Spontaneous gradual recovery 
from anesthesias in three months : Recovery from 
paralysis by reeducation in a few more weeks. 



Case 587. (Binswanger, July, 1915.) 

A German youth of 19 volunteered at the outset of the 
war as a motor cycle rider. About the end of October, he was 
hurled from his wheel by a shell which struck close beside 
him and exploded, knocking his back against a pile of beams. 
He lost consciousness. There may have been hemorrhage. 

He came to, two hours later, in the dressing station, hardly 
able to move his limbs. Such movements as he could make 
were painful. There was an evident contusion of the back. 
He had a fainting fit after his bath in the field hospital and 
then could get to bed only with support. Severe pains in the 
legs, especially in the knee. 

In the reserve hospital, there was a second similar fainting 
spell, followed by buzzing in the head, feelings of pressure in 
the chest and an irregular pulse; all of which phenomena 
disappeared the morning after the fit. 

A careful examination about the middle of November 
showed the persistence of a severe paresis of the left arm, 
and a less marked motor weakness of the right arm. Both 
legs were paretic, and there were no spontaneous movements 
of the leg. This paresis of the legs was combined with 
complete anesthesia and analgesia. Sensory impairment 
was found only in the right arm and trunk, and there 
was no evidence of sensory impairment in the left arm. 
Both motor and sensory disturbances of the arm disappeared 
rapidly. 

However, at the beginning of December, 19 14, the complete 
insensibility of the lower extremities up to the groin still 
persisted. The anesthesia then began to retreat, so that four 
days later, the upper limit of anesthesia was somewhat below 
the groin. There could be found a circumscribed area 
of anesthetic skin over the os sacrum up as far as the second 



TREATMENT AND RESULTS 825 

vertebra of the os sacrum; but the skin around this area, 
as well as over each tuber ischii, gave normal sensation. 

The anesthesia continued to retreat: to the middle of the 
thigh at the middle of December; to a level 3 cm. above the 
knee-cap at the end of December; to the upper end of the 
knee-cap on the right side and the middle of the left knee- 
cap, January 1. January 11, the anesthesia had retreated 
to a level 10 cm. below both right and left patella. February 
8, sensibility in the legs had entirely returned. 

While the anesthesia was pursuing this favorable course, 
the motor symptoms failed to improve to any marked extent, 
although active motion of the legs with the patient in dorsal 
decubitus had gradually returned to a limited degree. 

The diagnosis upon arrival at the Jena Nerve Hospital 
was " rheumatism of the left side of the body and dislocation 
of the spine." 

The treatment consisted at first of rest in bed and moist 
dressings of the legs, but the treatment had to depend greatly 
upon the diagnosis. The patient complained of difficult 
micturition; yet there were no other positive signs of or- 
ganic disease, of spine or cord. 

Hysteria was the diagnosis preferred to rheumatism, de- 
spite the fact that examination at the Jena Hospital failed 
to show any disorder in pain or tactile sense. 

The patient was a rather tall man of slender build, with 
a slightly accentuated second pulmonic sound, decidedly 
increased tendon reflexes, weak plantar reflexes, and many 
points painful on pressure in various parts of the head, over 
the spine, and in the sciatic regions. The vertebral sensi- 
bility to pressure was most acute in the region of the third, 
fourth, and fifth thoracic vertebrae. There was a marked 
dermatographia. There was no other sensory disorder and 
no motor disorder of the arms, though the left hand-grasp 
was weak. All passive movements could be successfully 
carried out with the legs. Upon bending at the hip, there 
were subjective feelings of tension in the posterior parts of 
the thighs. In active motion there was a marked limitation 
in leg movements, which appeared to be executed with great 
difficulty with but small excursion and with considerable 



826 TREATMENT AND RESULTS 

trembling. The knee-joint could be flexed only when the 
sole of the foot had support. The lower leg could not be 
extended. The excursion in the joints of the feet and toes 
was slight. Muscular strength was in general decreased. 
There were no feelings of pain in muscular action but merely 
feelings of great effort. Gait was slow, shuffling, unsteady, 
hesitating and only possible with support. Fatigue set in 
after a few steps. In walking, the legs could hardly be bent 
at the knee. The soles of the feet dragged on the ground. 
The patient was unable to stand upright, and when placed 
upon his feet, anxiously and stiffly clung to some support. 
Without support, he fell over backwards. When supported 
he could move his legs at the hip and lift the feet from their 
base by bending the knee-joints. The patient could not sit 
in a chair or in bed except with support ; otherwise he would 
fall to the right side. In dorsal decubitus he complained of 
pain in the loins. 

With this hysterical picture, treatment of a psychothera- 
peutic nature was carried out. The patient was given 
methodical exercises in walking and standing, during which 
affirmative suggestions about his new capacity to walk and 
stand were^given with monotonous repetition. 

For the first fortnight he walked with the support of two 
nurses for a half hour every day. He was very industrious 
and willing to execute this treatment; and later began to 
exercise with a cane. Two days later, he omitted the cane 
and found himself able to walk about without support. He 
was shortly able to stand without swaying, although for 
some time the walk was upon a rather wide base and some- 
what slow and suggestive of spastic paresis. 

The general condition of this patient remained good. His 
appetite and sleep were good. After the middle of March, 
1 91 5, there were no more peculiarities in walking, and the 
patient was able to take somewhat long walks in the city 
and vicinity. He applied for work in the airship division, 
for which he already possessed some experience. 

The youth appears to have been of a normal mental and 
bodily development, though his mother is said to have been 
nervous and a sister died of convulsions in childhood. 






TREATMENT AND RESULTS 827 



Shell-shock with loss of consciousness: Deaf- 
mutism, rhythmic head movements, anesthesia, 
asymmetrical areflexia. Recovery by suggestion 
with faradism, massage and reeducation. 



Case 588. (Arinstein, September, 191 6.) 

A Russian private, 30, literate, lost consciousness upon the 
explosion of a large shell, November 10, 191 5. He was 
brought to hospital, November 14, completely deaf and dumb, 
and with his head rhythmically swaying sidewise 60 to 70 
times per minute. The swaying ceased during sleep. The 
head was carried inclined to the right; there was complaint 
of headache. The left leg, the trunk and the hairy part of 
the head were anesthetic. The knee-jerks were obtained 
with difficulty, the Achilles jerks were lively; the throat and 
conjunctival reflexes were absent ; the abdominal and cre- 
masteric reflexes were lively. The right plantar reflex was 
absent; the left normal. The vision of the right eye was 
impaired, and there was a monocular diplopia of this eye. 
The drum membranes were pulled in, and the disorder of 
hearing was explained on the basis of labyrinthine shock. 

After a seance of written suggestion with faradism to neck 
and small palate and vibratory massage to throat, speech 
returned. November 26, the patient read in a loud voice a 
written phrase. He did not speak again independently until 
early in December, when he read aloud written matter. 
The return of spontaneous speech was gradual. Hearing 
returned December 5, when he was able to hear in the right 
ear by means of a tube. In the sitting posture there was less 
swaying of the head. If the patient lay down, rhythmic 
movements of the head became stronger and more rapid (120). 



828 TREATMENT AND RESULTS 



Shell explosion ; unconsciousness : Amnesia ; pa- 
ralyses. Reeducation. 



Case 589. (Batten, January, 19 16.) 

A corporal in the Belgian army was mobilized when the 
war broke out, and was in action continuously in the retreat 
from Liege, in the siege of Antwerp, and finally on the Yser 
until October 27, 1914, when the explosion of large shells 
rendered him unconscious. He recovered consciousness only 
in hospital at Calais. Though he was able to see and hear 
well, he was dazed and remembered nothing of what had 
happened. In fact, he did not understand what was said to 
him. 

In a week's time, his memory and intelligence returned, 
save for periodic attacks in which he was dazed. From the 
very beginning he had been quite unable to move his legs, and 
at first the arms were weak. He had a series of attacks of 
violent struggling in November and December, 1914, which 
the corporal himself called fainting attacks, claiming that 
he did not move his legs in the attacks but only his arms. 
In fact, he claimed that he could move neither head, body, 
nor legs, but only the arms. He said, " Sometimes I try 
hard and set my teeth, but I do not know how to move my 
head and my legs; I try but they do not move." Sphincter 
control was maintained. Although he could see, when he 
attempted to read, everything went black. 

He was finally admitted to the National Hospital for the 
Paralyzed and Epileptic on July 8, 191 5, on the service of 
Major Walshe. He was thin and wasted. He was firmly 
convinced, according to the notes of Major Walshe, that he 
was seriously paralyzed. He said he could not lift his head; 
when his body was lifted, his head fell back, or rather perhaps 
was definitely thrown back, lolling about alarmingly. How- 
ever as he lay in bed he frequently lifted his head uncon- 
sciously and placed his hands under it. When asked to lift 
his head, the sternomastoids were strongly contracted, but 
at the same time the neck extensors also, so that the head was 



TREATMENT AND RESULTS 829 

stiffly and strongly held in an extended position. Despite 
the patient's statement that he could not move the trunk" 
muscles, he could turn over readily in bed, and when trying 
to move the head the trunk was fixed in a strong opisthotonos, 
and the abdominal walls were rigid. When requested to 
move his legs, he made no movement whatever, though 
during head movements the legs were strongly fixed in ex- 
tension. On passive movements, there was no active mus- 
cular resistance. There was an indefinite blunting of all 
kinds of sensations. Reflexes were normal. 

Major Walshe worked hard with the patient, inducing him 
first to lift his head from the pillow, and finally to move the 
legs. In three weeks' time, the corporal could just sit up, 
and at the end of another month, he was able to stand in the 
walking machine. At the end of a third month, he was 
walking upon crutches, and at the end of another, he could 
walk upon two sticks with his feet wide apart, moving as if 
glued to the floor. To quote Batten, " The corporal will 
eventually get well but not, I think, before the end of the 
war." 



Cosi od' is che solava la lancia 

d'Achille e del suo padre esser cagione 
prima di trista e poi di buona mancia. 

Thus I have heard that the lance of Achilles, 
and of his father, used to be occasion 
first of sad and then of healing gift. 

Inferno, Canto xxxi, 4-6. 



830 



E. EPICRISIS* 

Terminology 

i. Shell-shock, a lay term, usually refers to the medical 
entity or disease-group: functional neurosis, or more briefly, 
neurosis. 

The history of the term Shell-shock will repeat that of 
Railway Spine in the last century; the term will fall into 
disuse when the cases subsumed thereunder get their exact 
medical diagnoses — which, statistically speaking, will prove 
to be as a rule psychoneuroses, either hysteria (pithiatism), 
neurasthenia (nervous exhaustion, " prostration"), or psychas- 
thenia (obsessive neurosis). 

2. But the laity cannot be got to use the term Shell-shock 
in this exact sense, because the laity cannot make exact 
diagnoses. 

In the post-bellum and reconstruction period the physician 
will need to guard against regarding all cases called Shell- 
shock as really neuroses, merely on the ground that Shell- 
shock is probably neurosis. Laymen will in the reconstruction 
period succumb to the lure of the ioo per cent and gossip about 
cures and failures in the same loose manner that is but too 
familiar in discussions of Lourdes, Christian Science, the 
Emmanuel Movement. It will be worth while to preserve 
a certain generality and comprehensiveness for the term 
Shell-shock, which will stand to medicine as the term weeds 
stands to botany. 

3. In short, keep the connotation but try not for any 
denotation of this lay term Shell-shock in the lay mind! 

The dangerous history of the term dementia praecox may 
be recalled. Neither dementia nor praecox is an exact term 

* Material is here drawn passim from the compiler's Shat- 
tuck Lecture on Shell-shock and After, read before the 
Massachusetts Medical Society, Boston, June 18, 191 8. 

831 



832 EPICRISIS 

except for the statistical majority of cases of schizophrenia 
Yet does not the layman hearing the term dementia feel 
entitled to assume that a victim must be demented or become 
so? 

4. The term Shell-shock appears to be a perfect term for 
the ordinary man, as it means much and little, connotes 
enormously and denotes a minimum and casts the lay hearer 
back upon the expert. 

But confronted by the term Shell-shock, the ardent social 
worker or the ordinary man fails to get any incorrect notion 
about the nature, and especially about the prognosis, of the 
condition. If there is any suggestion of prognosis, it is the 
correct suggestion of curability possibly conveyed by the 
suddenness implied in the term shock; but I defy the ordi- 
nary man to get from the ordinary term Shell-shock very much 
that denotes anything in particular. All he gets is an enor- 
mous connotation. This connotation may run back for the 
race into tree stumps, savages brandishing spears, palatial 
decorations, the protrusion of animal spirits, the Leyden jar 
(sometimes familiarly known as the " shock bottle"), and the 
aspen shaking of the man in fear or its interior equivalent. 
But whether the slang runs back so far or no, and whether the 
shell is a shell of powder or a shell of fear, and whether the 
shock is of solid particles or in a moral sense, the problem 
is implicitly laid down in the slang (see historical discussion, 
Shattuck Lecture). 

5. The terminological difficulties are clarified somewhat by 
the French distinction of etats commotionnels and etats 
emotionnels in the Shell-shock group. 

The French very neatly distinguish what they term etats 
commotionnels from etats emotionnels. They think of the 
etats commotionnels or commotional states much as we think 
of commotio cerebri, that is, of a physico-chemical happening 
in the brain of an essentially curable (or reversible) nature ; 
that is, of something that falls short of being, as they say, 
lesionnel, namely, as bringing about a structural lesion. That 
is, they distinguish a brain with a visible focal lesion from 
one which has sustained a physical jar or commotion, and they 
distinguish the effects of both of these from the etats emotion- 






EPICRISIS 833 

nets or emotional effects of an injury. The nomenclature hejre 
brings out one of the most fundamental difficulties in the 
whole field of so-called Shell-shock, namely, the distinction 
between structural conditions, microscopic or macroscopic, 
on the one hand, and functional conditions of a psychopathic 
nature, on the other. The commotion would affect the neu- 
rones themselves in some perhaps invisible but still genuine 
physico-chemical way, whereas the emotion would affect 
these neurones merely after the manner of the normal emo- 
tional life, except that the neurones would perhaps deliver 
an excessive stream of impulses. 

6. Terminology, especially in the matter of explanations 
to laymen (Americans demand monosyllabic explanations as 
a preliminary to taking suggestions!), is not always assisted 
to clearness by physicians on account of the old ontological 
fallacy that Charcot insisted on. 

Would that the medical profession understood neuroses at 
their true value! Only too frequent is the impression on the 
part of the profession that imaginary symptoms are by the 
same token non-existent! I have even heard a physician well- 
trained in somatic lines say that Shell-shock did not exist be- 
cause Shell-shock was nothing but neurosis, and neuroses were 
characterized by imaginary symptoms, — accordingly neu- 
roses, being imaginary, do not exist! All of which reminds us 
that many of the profession were entirely skeptical when 
Charcot made his original observations. Some men here in 
America felt that, whereas hysteria might occur in Paris, it 
did not occur to any extent in America. The Shell-shock 
data of this war will abundantly prove to the profession the 
existence of the neuroses, and I feel that physicians will have 
to brush up their ontology to the extent of conceding that 
a symptom may be in a sense imaginary and yet not in any sense 
non-existent. 

7. Babinski points out a case of hysterical paralysis of a 
leg which led the patient to lean so heavily upon his arm as to 
produce an organic crutch paralysis. It would be to no 
point to argue that the hysterical paralysis was here non- 
existent. Of course we shall have to meet the false analogies 
drawn from methods of cure. If a paralysis can be cured in a 



834 EPICRISIS 

few minutes by the electric brush, or by hypnosis, or on emer- 
gence from chloroform, or by some other modern miracle, 
8. Is it too much to ask the profession not ever to say that 
this rapid and seemingly miraculous cure was brought about 
because the disease was non-existent? 



Diagnostic Delimitation Problem 

9. The delimitation problem, taken up in Section A, is not 
identical with the differentiation problem, taken up especially 
in Section C but passim in Sections B and D ; by delimitation 
we may refer to the process of localizing the diagnostic battle 
through exclusion of the other great groups of mental diseases 
that a priori ought not to come in question, but do come in 
question sometimes, before we slice down to the question, 

10. Is there or is there not evidence of destructive lesion 
in the nervous system of this so-called Shell-shocker? Is 
this man a victim of organic or of functional neurosis? This 
latter is what may be termed the differentiation problem. 

Confining ourselves now to the delimitation problem, 
what are the major groups of mental diseases that might 
come in question? 

I shall enumerate these. We think of mental diseases as 
I, syphilitic; II, hypophrenic (that is, feeble-minded in some 
of its phases, including even slight degrees of subnormality 
not entitled to be called feeble-minded in the ordinary sense) ; 
III, epileptic; IV, alcoholic (or due perhaps to some drug or 
poison) ; V, encephalopathic (in the sense of some focal brain 
disease) ; VI, symptomatic (in the sense of some somatic 
disease); VII, senile (or presenile). The seven groups so far 
enumerated, I believe, the general profession is pretty well 
equipped to consider, at least roughly to diagnosticate and 
to handle with due respect to the interests of the patient and 
of the community. I am bound to say that some of my col- 
leagues would not go so far as to the competence of physi- 
cians in general in these fields, and one is aware that a plenty 
of mistakes have occurred even in these groups through the 
bad judgment of practitioners. Nevertheless, I hold to the 
conception that our profession is reasonably well equipped to 



EPICRISIS 835 

handle these greater groups, having in mind all the while the _ 
appropriate temporary calling-in of the specialist. But 
there are two more groups, in addition to these seven, in 
which I am not so sure that the general profession knows as 
much as it should. I refer to VIII, the schizophrenic group, 
commonly known as the dementia praecox group; and IX, 
the cyclothymic group, sometimes termed the manic-de- 
pressive group. It is the victims of the diseases that con- 
stitute these latter groups that ought unconditionally to be 
excluded with few exceptions from the army; and it is the 
study of these conditions which ought to be carried out as a 
part of every man's post-graduate training, not merely for his 
work on draft boards, but for his work in civilian and recon- 
struction practice. There is another group of, X, psycho- 
neuroses, with which the profession regards itself as familiar, 
and with which it doubtless is familiar, in what might be 
called blooming examples of hysteria, neurasthenia, and psy- 
chasthenia. But the nub of the situation lies in the fact that 
the diagnosis of instances which are not such blooming ex- 
amples is difficult, and hence it was that I qualified my state- 
ment as to the competence of the practitioner in this tenth 
group. It is, of course, the tenth group, of psychoneuroses, 
into which the majority of the Shell-shock cases fall. 

11. Now a study of the literature of the belligerents having 
Shell-shock in mind as its special topic and aim proves to re- 
quire a study of war literature in all of these groups. There 
are cases of so-called Shell-shock which even well-prepared 
medical men have placed in the neurosis group, when they 
should have been placed in one or other of the groups men- 
tioned. 

12. In short, whereas the Shell-shock delimitation prob- 
lem deals with groups, I, II, III, IV, VI, VIII, IX and (as 
our compilation shows) especially with groups I, III and VI, 
on the other hand the shell-shock differentiation problem 
deals primarily with groups V and X. 

To clear the decks for action re the differentiation problem, 
let us dismiss the major troubles of the delimitation problem 
as shown in groups I (syphilitic), III (epileptic), VI (somatic) 
and thereafter very briefly refer to the residue of the delimi- 



836 EPICRISIS 

tation problem. For convenience of reference, a few out- 
standing remarks concerning the general relations of these 
divisions to war and peace conditions are inserted here. We 
dealt in the diagnostic order of exclusion with 190 cases, 
distributed as in the table below (bear in mind that the method 
of this book precludes attaching great statistical weight to 
the comparative figures, since the various authors published 
their cases for their special rather than their typical interest) . 

I. Syphilopsychoses 34 

II. Hypophrenoses (feeble-mindedness and imbecility) 18 

III. Epileptoses 33 

VI. Pharmacopsychoses (alcohol; morphine) 17 

V. Encephalopsychoses (focal brain lesion cases) 15* 

VI. Somatopsychoses 29 

VII. Geriopsychoses (senile — a null class) o 

VIII. Schizophrenoses 16 

IX. Cyclothymoses 7 

X Psychoneuroses 12* 

XI. Psychopathoses 15 

196 

13. The neuropsychiatry side of syphilis in the war 

is presented in 34 cases (Cases 1 to 34). The syphilitic 
basis of sundry military difficulties, quite unsuspected by the 
laity and probably not too well understood by service men, is 
suggested by Case 1 , a case of desertion by a French officer of 
high rank. Nor is Case 2, in which visions of submarines 
proved syphilitic, without its warning. Such cases point only 
too obvious a moral : 

14. Neurosyphilitics have no place in the army or navy. 
Eight cases (Cases 3-10) follow in which the aggravation or 

acceleration or liberation of neurosyphilis has come about 
under the conditions of war. Some of these cases suggest 
the gravity of the problems of compensation, allowance and 
pension that may arise. We might ask, 

15. Should not a government which enlists a syphilitic 
pay full allowances to him when under war conditions he 
becomes a neuro syphilitic? 

* The numbers of focal brain lesion cases and of psycho- 
neuroses must naturally be considered in relation to the great 
groups of these cases in Sections B and C. 



EPICRISIS 837 

* 

For the government was theoretically able to learn at th^ 
start (within a small margin of error by means of the serum 
test) whether the man was syphilitic. If a one-eyed man loses 
his remaining eye in an industrial accident in civil life, his 
damages are often fixed at damages for total blindness; for 
the industrial firm should not have employed a one-eyed man 
in an industry dangerous to eyes. The principle cannot differ 
with a man hired in a spirochete-bearing state: The com- 
pany has hired a man who may under traumatic conditions 
become an incompetent neurosyphilitic, and should pay 
damages accordingly when the aggravation begins. 

16. What are the responsibilities of government if the 
neurosyphilis is due to a syphilis acquired during the war? 

Often such infection may be due to a tragical form of 
" negligence. " But, as pointed out in a work on Neuro- 
syphilis, 19 1 7, I believe that any form of licensing system, 
official or virtual, which would permit the purchase of syphilis 
in or near military zones, abolishes the argument of " negli- 
gence." A man acquiring syphilis under the connivance of 
government ought to stand as well as a syphilitic hired by the 
government, when it shall come to the question of compen- 
sation for incapacity. Yet, it may be argued, the man 
might have remained continent after all. The point is left 
to the mercy of jurists. 

17. The share of neurosyphilis in the "crimes" and 
disciplinary problems of the army is intimated in three cases 
(Cases 11 to 13). 

18. The latter part of the series (Cases 14 to 31) embraces 
problems of a more medical nature, touching traumatic 
paresis and "Shell-shock paresis." Unusual, these cases 
may be readily conceded to be; but their infrequency is not 
such as to put them out of the field of consideration in the 
" Shell-shock " group. 

Very intriguing to the diagnostician would be the cases of 
pseudotabes and pseudoparesis (Cases 23 and 26 of Pitres and 
Marchand), were such cases at all frequent. 

Case 28, in which shell-shock (the physical event) ap- 
parently caused recurrence of a syphilitic (!) hemiplegia, is 
particularly instructive and might better belong with the 



838 EPICRISIS 

series (under Section B: Nature and Causes, Cases 286-301) 
in which ante-bellum weak spots were picked out by shell- 
shock and war conditions. But Case 28 is placed here for its 
syphilitic interest. 

Case 29 stands out as a warning example not to crowd the 
hypothesis and try to make syphilis sponsor for everything, 
even when it plainly is at work. 

Cases 32-34 are cases in which syphilis played a part, 
though possibly a minor part, in certain peculiar mental 
reactions. 

To sum up the part played by syphilopsychoses and syphilo- 
neuroses in the war, we find, that 

19. Syphilis may have occasionally a serious military 
effect, as in the case of desertion by a French officer of high 
rank. 

20. Important problems of pension, retirement, and com- 
pensation are brought out, and as no previous war has had 
the benefit of the Wassermann reaction and other exact tests 
bearing upon the nature, progress, and curability of neuro- 
syphilis, we may hope for a far more scientific determination 
of these questions by review boards during and after the war. 

21. We find a few instances in which neurosyphilis has 
played a part in the discipline of troops. According to one 
author (Thibierge, 191 7), syphilis has become a genuine epi- 
demic among French soldiers and mobilized munition workers. 
In Germany, also, it may be remembered that Hecht has 
claimed that no less than an equivalent of sixty army divisions 
has been temporarily withdrawn from fighting on the Teu- 
tonic side for venereal diseases. In this connection, Neisser 
had recommended the giving of salvarsan and mercury in the 
trenches. According to Hecht, the appearance of syphilis 
should be a signal for sending a man to the front. Hecht 
also made the somewhat bizarre suggestion that special com- 
panies of syphilitics should be formed, for convenience of 
treatment, on the firing line. 

22. A more solid foundation is laid for the theory that 
general paresis may be evoked by trauma — a conclusion 
already fairly well established by civilian cases, notably those 
of industrial accident. 









EPICRISIS 839 

23. The question whether shell-shock (the physical events 
can produce general paresis is probably to be settled in the 
affirmative, for it may always prove difficult to show that the 
physical shell-shock did not actually produce mechanical 
molar lesions of the brain, permitting the rapid advance of 
spirochetes. It is perhaps easier to prove that shell ex- 
plosion may precipitate neurosyphilis in the form of tabes 
dorsalis (take, for example, Cases 21 and 22). The cases 
of most importance in the question of traumatic neurosyphilis 
and traumatic paresis are cases 20, 21, 22, 24 and 25. 

24. The picking out of preexistent weak spots by Shell- 
shock is given clear illustration, as in the case of Shell-shock 
recurrence of an old syphilitic hemiplegia (Case 28). Only 
on such a basis could the syphilitic ocular palsy of Case 19 
be satisfactorily explained. 

25. The coexistence of functional phenomena with or- 
ganic syphilitic phenomena is demonstrated by Cases 29 and 
30; perhaps also in Case 16. 

26. It must be said that presumably there will be, unless 
our authorities are more successful than in the past, a con- 
siderable increase in venereal disease as the result of army life 
in wartime. There will be a certain number of cases of 
neurosyphilis a number of years after discharge from the 
army caused by infection acquired during service. (Ger- 
many is said to have got its crop of neurosyphilis after the 
War of 1870, in the early eighties of the last century.) The 
names of all soldiers acquiring syphilis and not considered 
cured at the time of discharge should, under ideal conditions, 
be given to health organizations in their home states so that 
they may be accorded proper care and treatment. 

27. Shell-shock and epilepsy. The authorities have been 
somewhat surprised by the number of epileptics that have 
gotten by the draft boards. The statistics are not yet ripe, 
but certainly the enlistment of an epileptic is not a rarity. 
There are some singular instances in the war literature show- 
ing how hard it sometimes is to bring out epilepsy. There is 
the English case, for example, of a man, an epileptic's son, 
who had himself been epileptic from 11-18, who entered the 
Expeditionary Force at the outbreak of hostilities, went 



84O EPICRISIS 

through the retreat from Mons and through two years of 
active warfare without having a single epileptic convulsion. 
In fact, in September, 191 6, he was put in charge of eight men 
on guard duty. Apparently the new responsibilities worried 
him, and two months later he had become epileptic to the 
extent of petit mal. 

Another man who had never been epileptic (though his 
sisters had been) was wounded four times, was never worried 
by shell fire, got somewhat depressed after the death of his 
father and five brothers in the service, but did not become 
epileptic until fina ly he was blown up and buried three 
times in one day, and it was a whole month later when he 
became epileptic, although treatment by rest and bromides 
apparently resolved the affair. 

Other cases seem to show that war experiences can bring 
out epilepsy, although n most instances it would appear that 
there was an epileptic or otherwise neuropathic heredity in 
these cases. 

28. There is one author, Ballard, who has actually pro- 
pounded a theory of Shell-shock as epileptic, pointing out 
the occurrence of epilepsy long after the early symptoms of 
Shell-shock have disappeared.* There does not appear to 

* In one instance, fugue and other minor symptoms were 
later replaced by epilepsy; in another, an epileptic confusion 
developed eight months after an explosion, and in a third, a 
case of mine explosion, stammering resolved into mutism 
and mutism finally into epilepsy. Of course there is a so- 
called general resemblance among all forms of hyperkinesis 
or irritative discharge of the nervous system. If we term 
epileptic all the things that various authors have termed epi- 
leptoid, we may be doing nothing more than to say that we 
believe these cases all subject to epileptic hyperkinesis. 
In that direction, of course, it has long been said that dipso- 
mania was really a form of epilepsy. Whether Shell-shock is 
ordinarily subject to recurrence in such wise as to imitate 
the recurrence of attacks of dipsomania, of manic-depressive 
psychosis or of epilepsy, is, to say the least, doubtful at this 
time. 



EPICRISIS 84I 

have been any increase in epileptics as the result of the war r 
either from the standpoint of Shell-shock or from the stand- 
point of brain injury, so far as the records of the National 
Hospital for the Paralyzed and Epileptic in London are able 
to show. 

29. As in all other instances of mental or nervous disease, 
when an epileptic returns from the war, whether or no he 
was potentially or actually an epileptic before the war, his 
relatives are bound to term him a case of Shell-shock. I 
am familiar with a case in a hospital in a certain Atlantic port, 
a case of pronounced and obvious epilepsy. In the wards he 
is treated as the hero of every occasion. Not only the nurses 
and attendants, but the other patients and often the physi- 
cians can hardly resist thinking of him as somehow a case of 
Shell-shock. It is a comment upon the status of mental 
hygiene in general that this self-same epileptic, had there been 
no war, would have been, as it were, a common or garden 
epileptic, mute and inglorious on some sunny hillside. 

30. In passing I may note how many instances in the 
medicolegal part of the war literature there are of epileptics 
who come up for courtmartial or for medical examination 
pending courtmartial. We may suspect that many a case 
of epileptic fugue has been regarded as a case of desertion. 
There is the case of an epileptic who left camp one morning 
and got drunk. Investigation showed that he left camp 
before anything epileptoid had happened. He developed in 
his drunkenness a pretty clearly epileptic crisis with great 
violence, for which he had a complete loss of memory. The 
French Council condemned him to five years of labor, not 
admitting in this instance that responsibility was diminished 
by reason of the man's being epileptic. In short, from the 
military point of view, he should, so to say, have known 
enough not to have gotten drunk, and so have avoided get- 
ting his epileptic crisis. Of course the decision was here 
very close, and a like decision would not always be rendered. 
To add to the complication of this particular case, the very 
first epileptoid crisis which caused it to be known that the 
man fell into the epileptic group was due to Shell-shock, or 
at least developed immediately after the bursting of a shell 



842 EPICRISIS 

nearby. On the whole, however, the relation between epi- 
lepsy and Shell-shock is not a close one. 

31. The question of epilepsy in the war is considered 
in a series of 33 cases (Cases 53-85). The considerations 
range from banal cases developing quite incidentally, up 
to cases regarded by one author (Ballard) as illustrating 
a theory of Shell-shock as epileptic (Cases 82-84). First 
are considered two cases actually syphilitic. In the first 
(Case 53), the diagnosis had to be revised from epilepsy 
to neurosyphilis (the convulsions of this neurosyphilitic were 
brought out by alcohol, and the reporter, Hewat, remarks 
that the serum of any patient developing epileptiform seizures 
between 35 and 50 years of age should be subject to test). 
In Case 54, the soldier got his syphilis in wartime and the 
syphilis acted to bring out an epilepsy with which the patient 
was hereditarily tainted (epilepsy syphilogenic, i.e., reactive 
to syphilis). 

Case 55 might perhaps better have been considered in 
the group of hypophrenoses, as he was epileptic and imbecile. 
He was at first condemned by court martial to five years' 
imprisonment for leaving his post in the presence of the 
enemy. 

Another mixed case is Case 57, in which another feeble- 
minded subject showed seizures of a psychogenic nature, 
which he was able eventually to stop by clenching his teeth. 

Seven cases (Cases 58-64) are cases of a disciplinary nature, 
amongst which attention may be called to Case 62, the 
" specialist in escapes." The medicolegal questions of re- 
sponsibility in the drunken epileptic (Case 58) are particularly 
perplexing. 

32. Case 64 is one of epilepsy following antityphoid in- 
oculation one-half hour. There were five attacks during a 
fortnight and then no others. The antityphoid inoculation 
came eight weeks after a shell wound of the thigh, which 
had not served to bring out the epilepsy in this patient. 
BonhoefTer had three other instances of the sort: one in a 
severely tainted subject, and the others in alcoholics. 

33. The next group of cases, 66-77, yields a series of the 
most interesting medical problems, some of which scarcely 



EPICRISIS 843 

belong in an account of psychoses incidental in the war*, 
Case 66 is one with recovery from Jacksonian seizures after 
decompression of the upper Rolandic region, which was edem- 
atous following an (apparently very slight) scalp wound and 
shell-shock. 

34. The cure by studied neglect (in Case 67) is one of 
hystero-epileptic convulsions occurring in series. Case 68 
demonstrates the superposition of hysterica phenomena over 
a genuine epilepsy, a case therefore with two diagnoses: not 
hystero-epilepsy, but epilepsy and hysteria. 

35. The theoretical implications of Case 69 are striking: 
The case was one of musculo-cutaneous neuritis (gross en- 
largement), in association with which Brown-Sequard's 
epilepsy developed, waxing and waning with the disease of the 
nerve. Another case of possible reactive epilepsy is Case 70, 
and a case of epilepsia tarda brings up the same issue (Case 
71). Cases 72-74 are cases with strong psychogenic compo- 
nents, of which Case 74 is particularly instructive on account 
of the gradual building up of a remarkable visual aura of an 
approaching fire- wheel, this aura developing after scotoma 
from looking at the sun. Cases 75 and 76 are cases of some- 
what doubtful epilepsy, one of fugue and the other of a soli- 
tary epileptic episode following 38 artillery battles in two 
months. 

36. Friedmann discusses narcoleptic seizures, regarded as 
due to the brain fag of trench life (Case 77). Sham fits and 
epileptoid attacks controllable by will appear in Cases 78 and 
79 respectively. Case 80 is a striking case of a man with 
epileptic taint, which two years' service, four wounds, the 
death of a father and five brothers, and eventually Shell- 
shock and burial thrice in one day, served at last to bring out. 

37. Shell-shock and bodily disease. In civilian psycho- 
pathic hospital practice, if a case is not syphilitic, not feeble- 
minded, not epileptic, not alcoholic, and without signs of 
intracranial pressure or disorder of reflexes, then we, as special- 
ists, must consider whether the disease in question is not due 
to some form of bodily disorder outside the nervous system; 
for example, we think in practice of infectious psychoses, of 
exhaustive states such as the puerperium, of toxic states 



844 EPICRISIS 

such as may be found in cardiorenal cases, and of glandular 
phenomena such as we are familiar with in the thyroid dis- 
orders. 

Under the war conditions, it might be thought that these 
somatic disorders yielding the so-called symptomatic mental 
diseases would be frequently found. 

Aside from these rarities in puzzling diagnosis, we find more 
commonly in the literature evidence of 

38. The soldiers heart, the so-called "D.A.H.," or dis- 
ordered action of the heart, of the English army reports. 
This soldier's heart is sometimes associated with hyperthy- 
roidism, and sometimes hyperthyroidism is found alone, 
with symptoms suggesting those of a sort of diffuse Shell- 
shock. 

One author claims rapid cures of hyperthyroidism by the 
relatively simple process of hypnosis. Perhaps this is not 
too unlikely in view of the r still obscure relations between 
mind and hormones. A little more surprising, perhaps, is the 
assertion met with that psoriasis is sometimes a Shell-shock 
phenomenon. 

The literature clearly shows, however, that, as in most 
special problems, the internist is still in demand. I recall 
how one internist was misled on the witness stand into stating 
that he was a " general specialist." This is what we would 
all need to be, were we to solve the problems of Shell-shock 
in the time allotted to us by the war. 

39. Following are special cases to show how near the 
somatic (" symptomatic") may be to Shell-shock. 

The somatic group of psychoses, sometimes termed symp- 
tomatic, is illustrated in 29 cases (Cases 1 18-146), and com- 
prises cases ranging all the way from rabic phenomena to 
those of hyperthyroidism. Possibly the first two cases 
(Cases 118 and 119) might better be placed among the en- 
cephalopsychoses. Case 118, one of rabies, was that of a 
farmer without history of having been bitten by a dog, who 
eventually came to autopsy and received the Pasteur In- 
stitute diagnosis of rabies. A diagnosis of angina was at 
first made. When the symptoms became more serious and 
masseter spasm developed, a question of tetanus arose. Later 



EPICRISIS 845 

the diagnosis of meningitis was suggested. At this point, the, 
symptoms became predominantly psychotic. 

Case 119 was one of seven cases reported by Lumiere and 
Astier, in which delirium and hallucinations appeared as ! a 
complication of tetanus. The case in question had been 
given anti- tetanic serum. (Another case showed identical 
symptoms without having been given anti-tetanic serum.) 

That a local tetanus could be mistaken for hysteria might 
seem ci priori unlikely, but Cases 120 and 121 indicate as 
much; and Case 121 is interesting on account of the officer's 
own description of his local tetanus and its treatment. A 
psychosis apparently related with dysentery occurred in Case 
122. Hysteria followed typhoid fever in Case 123. An- 
other form of typhoid fever complication is perhaps shown 
in Case 124, wherein the diagnostic question lay between 
dementia praecox and a post-typhoid encephalitis. 

Paratyphoid fever has diagnostic complications, as shown 
in Cases 125 and 126, wherein the mental symptoms out- 
lasted the fever (Case 125), and psychopathic taint was 
brought out (Case 126). 

Diphtheria was also represented in the matter of nervous 
and mental symptoms in Cases 127 and 128. In Case 127 
the nervous symptoms appeared eight days after evacuation 
for diphtheria. There were a few sensory symptoms (hyp- 
algesia, hypoacusia, and peculiar bone sensations) in this 
subject. The phenomenon in Case 128 was apparently one 
of hysterical paraparesis ; nor does it appear in this case that 
the hysterical paralysis was preceded by polyneuritis. 

Malarial effects are present in three cases (Cases 129-131), 
of which Case 129 showed an amnesia, Case 130 a Korsakow 
syndrome, and Case 131 anterior horn symptoms. Case 
132 exemplifies 15 instances of acroparesthetic disorders in 
so-called trench foot. This case, like several others, is in- 
serted in this group, not because the symptoms are psy- 
chotic, but because they might cause diagnostic difficulty as 
against hysterical phenomena. 

Case 133 is an autopsied case of bronchopneumonia follow- 
ing bullet injury of the spine. Microscopic examination of 
the spinal cord showed small cavities in the first and fourth 



846 EPICRISIS 

dorsal segments. This myelomalacia was doubtless related 
with the bullet injury of the spine, although the spinal cord 
was not itself directly touched by the bullet. Case 134 might 
be regarded perhaps as one of Shell-shock and should be 
considered in relation with the cases at the head of Section B 
(Cases 197-209). The case might be regarded as functional, 
except for a decubitus that developed. Despite this decubitus, 
there was recovery. The case is placed in the somatic group 
on account of pulmonary phenomena which it seemed well to 
relate with those of Case 133. Compare also Case 136, in 
which reflex phenomena are associated with a bullet wound 
of the pleura. Case 135 is a many-sided case, with ante- 
bellum hysteria and certain Shell-shock phenomena. While 
under observation, the patient caught typhoid fever and then 
developed neuritis. This neuritis was very probably not 
post-typhoidal so much as hysterical. Accordingly, the case 
should be considered in connection with the ante-bellum weak 
spot series, Section B (Cases 286-301). There was in this 
case a cure by reeducation. 

The reflex hemiplegia with double ulnar syndrome in 
Case 136 seemed to have followed a bullet wound of the pleura. 
According to the authors, Phocas and Gutmann, there is 
considerable literature upon nerve complications of pleura 
trauma, including syncope, epilepsy, and (more rarely) hemi- 
plegia. 

Heart cases are illustrated by Cases 137-139: the first one 
of hysterical tachypnoea, and the others of the so-called 
soldiers* heart. 

Diabetes mellitus seems to have followed war strain and 
shell wound in Case 140. 

It is doubtful whether shell-shock and burial had anything 
to do with the appearance ten days later of lipomata, which 
proved to be the initial phenomenon in a pronounced Der- 
cum's disease. (Case 141). 

Hyperthyroidism is illustrated in four cases (Cases 142-144). 
The first (Case 142) appears to have been cured by inducing 
deep somnambulism (Tombleson claims cures by suggestion in 
eight cases of hyperthyroidism). Neurasthenia or question- 
able Graves' disease (Case 145) followed Shell-shock. That 



EPICRISIS 847 

of Case 144 followed 10 months' service, at times under^ 
protracted shell fire. A forme fruste of Graves' disease is 
shown in Case 145, in which the phenomena followed gassing 
and shelling. 

A somewhat curious somatic complication in a case of 
Shell-shock hysteria was the finding of a needle in the left 
upper arm, which was then extracted. (Case 146). 

The Nature of War Neuroses 

40. Regarding our rough delimitation of the Shell-shock 
group as well in hand, having put upon one side three of the 
most disturbing groups (save one) in our process of demar- 
cation, we must proceed to the Shell-shock material itself : 
a material now definable as assuredly non-syphilitic, non- 
epileptic, non-somatic,* as beyond question without narrow 
relations with feeble-mindedness, alcohol and drug states, 
schizophrenia and cyclothymia, and as probably of the general 
nature of the psychoneuroses. 

Note that in this epicrisis I have designedly not followed 
the order of presentation of the text materials. The process 
of diagnosis per exclusionem in ordine which I find most 
serviceable in civilian psychopathic hospital practice is the 
elimination of possibilities in the order presented in Chart I 
or in Paragraph 10 of this epicrisis. Because this book will 
find its greatest use in peace times as a kind of illustrative 
commentary on the peace material that presents itself in 
general practice or in psychopathic hospital voluntary, 
temporary-care, and out-patient practice, I chose to arrange 
the delimiting material according to the order of the practical 
key devised for civilian practice. We may now profitably 
change our order of consideration and consider whether 

41. The most practical key or sequence of consideration 
in the endeavor to delimit Shell-shock neuroses is probably : 
Exclude (1) syphilis, (2) epilepsy, (3) somatic disease (of a 
sort able to produce " symptomatic " effects somewhat like 
those of Shell-shock) . 

* In the limited non-encephalic sense of the term somatic 
(" symptomatic ") of some writers. 



848 EPICRISIS 

Below I shall still permit myself some general words con- 
cerning the other more easily excluded groups because of the 
light which feeble-mindedness, alcoholism, schizophrenia, 
cyclothymia, and even old age can theoretically throw on the 
nature of Shell-shock. 

42. Suppose then that syphilis, epilepsy, and somatic 
(non-nervous) disease are out of the running, we come prac- 
tically down to the psychoneuroses, knowing that knotty 
problems are at hand in telling them from structural trau- 
matic effects: But, after all, what are functional neuroses? 
What do we really know about the neuroses other than to 
say that they are not distinguished by the existence of the 
structural lesions which characterize organic disease of the 
nervous system? Is not the definition of neurosis purely by 
negatives? However true this definition by negatives may 
be from the genetic and general pathological viewpoint, the 
work of Charcot and in particular of Babinski has yielded a 
number of positive features from the clinical viewpoint, 
which to some degree make up for the lack of anything posi- 
tive in the neurones themselves as studied post-mortem. 
An eminent German has recently declared that the data 
of this war itself go far to prove some of the long dubious 
contentions of the Frenchman, Charcot; and the work of 
Babinski during the war has strengthened and developed the 
conceptions of his master, Charcot, as well as the ante-bellum 
conceptions of Babinski himself. 

43. Let me insist that the problem is practical enough: 
Organic versus functional neurosis. The point I want to 
make is that, when so much theoretical doubt concerning 
organic and functional neuropathy holds sway, the practical 
doubts in the individual case under the varying conditions of 
civilian practice and in the upheavals of military practice, 
must be still more in evidence. Case after case described in 
the literature of every belligerent has passed from pillar to 
post and from post to pillar before diagnostic resolution and 
therapeutic success. Colleagues meeting, for example, at 
the Paris Neurological Society, find themselves reporting 
the same case from different standpoints, — the one an- 
nouncing a semi-miraculous cure of a case which another had 



EPICRISIS 849 

months before claimed only as a diagnostic curiosity. I^i 
the midst of such discussions and controversies, there must 
inevitably be a renaissance in neurology. 

44. In cases of alleged Shell-shock, the hypothesis of 
focal structural damage to the nervous system or its mem- 
branes has to be raised. 

Shell bursts and other detonations can produce hemor- 
rhage in the nervous system and in various organs without 
external injury. Thus a man died from having both his 
lungs burst from the effects of a shell exploding a meter away. 
Hemorrhage into the urinary bladder has been identically 
produced. Lumbar puncture yields blood in sundry cases of 
shell explosion without external wound, and Babinski has a 
case of hematomyelia produced while the victim was lying 
down, so that the factor of direct violence through fall can 
be excluded. In sundry cases, not only blood but also lym- 
phocytes have been found, sometimes in a hypertensive 
puncture fluid. 

45. Moreover, in cases of alleged Shell-shock there may 
be a combination of structural and functional disease. 

A herpes or the graying-out of hair overnight can suggest 
organic changes. A case may combine lost knee-jerks (sug- 
gesting organic disease) with urinary retention (suggesting 
functional disorder). 

46. Again, there is a group of war neuroses, especially 
clearly brought out in cases of ear injury, in which the func- 
tional disorder surrounds the organic as a nucleus. But 
these " periorganic " neuroses are no proof that the neuroses 
in question are organic in nature. Hysterical anesthesia, 
paralysis, or contracture may occur on the side of the body 
which has received a wound: the process of such a peri- 
traumatic disorder is, nevertheless, a functional process. 

47. But, when the problem is statistically taken, the ma- 
jority of cases of alleged Shell-shock without external wound 
prove to be functional, as indicated by their clinical pictures. 
Thus, after a mine explosion, a man was hemiplegic, tremulous 
and mute. After sundry vicissitudes, the tremors were hyp- 
notized away. Then the mutism vanished, to be supplanted 
by stuttering. Finally the hemiplegia remained. So far as 



850 EPICRISIS 

the mutism and the tremors went, this man might belong in 
the majority group of Shell-shock cases, namely, the func- 
tional group. Assuming the hemiplegia to be really organic, 
we should regard this man as a mixed case, organic and func- 
tional. 

48. But do we not know all we need to know or all we are 
likely to know about the neuroses already from old civilian 
studies? There are some cases without very close relations to 
the war : Thus, we conceive of (a) psychoneuroses incidental 
to the war and such that they might very probably have 
developed without the entrance ot war factors; and on the 
other hand, we conceive of (b) psychoneuroses (to be dealt 
with in extenso later) in which war factors (either physical 
Shell-shock or other factors) forcibly enter. There are in 
this group of incidental psychoneuroses 12 cases. The first, 
described as a constitutional intimiste, a psychasthenic en 
herbe, was one in which a hallucination was developed in 
the field, and in which three phases of a psychopathic nature 
— (a) over-emotionality, (b) obsessions, (c) loss of feeling of 
reality — developed. In this case the war work at first 
seemed to better the man's general condition, and he gave 
two years of effective service. This officer in effect invented 
his own Shell-shock equivalent in a hallucination of Germans 
appearing in his trench. The case may be compared with 
one described in Section B, namely, Case 347: that of a 
Russian soldier who developed perfectly characteristic war 
dreams, though his entire service had been rendered in the 
rear and he had not had experiences in action. 

Possibly Case 171, that of hysterical fugue, might be re- 
garded as one of Shell-shock, since two shells burst near him 
prior to his fugue. The man had had analogous crises, 
certified by Regis, in adolescence, and had received the 
diagnosis hysteria. In this instance, we are dealing merely 
with an habitual somnambulist who has a characteristic 
fugue following explosion of two shells. The war is in a 
sense responsible for the fugue, yet not directly, and the fugue 
would, without the stress and strain of war, probably never 
have developed (see sundry cases in the group in which ante- 
bellum phenomena are newly evoked in war: Cases 286-301). 



EPICRISIS 85I 

The hysterical psychosis of an Adventist (Case 172) might 
be regarded as liberated by military service ; the terrible fear 
of the guns shown by the psychoneurotic (Case 173) pro- 
ceeded to the point of fugue. A Shell-shock victim whose 
war bride was pregnant, developed fugue with amnesia and 
mutism (Case 174). Under hypnosis, it appeared that his 
fugue began with his running away from shells. Case 175 
was that of a neurasthenic who volunteered and had to be 
sent back from the front after three months. In this case, 
war dreams were supplanted by sex dreams, and the fear 
of insanity became ingrained. The phenomena here were 
largely ante-bellum and the war brought them out once more, 
as might other disturbing experiences. 

Case 176 is here introduced to show that neurasthenia may 
develop in a man without hereditary taint or acquired soil. 
There was a very slight shrapnel injury of the skull, which 
somewhat clouds the diagnosis in the case. Five months' 
war experience brought out the neurasthenia. Case 177 
deals with a point in the diagnosis of psychasthenia, which, 
according to Crouzon, shows arterial hypotension, a condition 
important to distinguish from that of pulmonary tuberculosis 
and of Addison's disease. Compare this case with Case 
169: a case of depression treated by pituitrin. Case 178 
is a case of psychasthenia following several months' service 
by a man who probably should never have entered military 
service. 

Another case of ante-bellum origin is Case 179. Anti- 
typhoid inoculation appears to have been the initial factor in 
the case of neurasthenia No. 180. Compare Case 65, epi- 
lepsy after antityphoid inoculation. Case 181 was that of a 
non-commissioned reserve German officer whose neuras- 
thenia was distinguished by sympathy with the enemy. He 
did not want to let his men shoot at the enemy because the 
idea came forcibly to him that the enemy soldiers had wives 
and children. This symptom of sympathy with the enemy 
was also shown by another German (Case 229). Compare 
the sentiments of a Russian under narcosis (Case 555). 

To sum up concerning the small group of psychoneuroses 
presented in the section on Psychoses Incidental in the War, 



852 EPICRISIS 

we are dealing with cases in which the phenomena are either 
continuous with ante-bellum phenomena, or are of such a 
nature that they might well have been brought out by other 
factors than those of war. These cases by the design of their 
choice throw little or no light upon the relation of physical 
shell-shock or its equivalent to the psychoneuroses, though 
in a few instances the factor of shell explosion is not entirely 
to be excluded, and in one instance (Case 170) a hallucination 
may be regarded as a virtual equivalent of an emotional shock 
of great compelling power. 

Examples are available of hysteria (Cases 171, 172, 173, 
174), of neurasthenia (Cases 175, 176, 179, 180, and 181), 
and of psychasthenia (Cases 177, 178, and possibly 170). 

49. Let us now contrast with these specified ante-bellum 
or non-war cases the situation which will face us in the war 
group. 

Section B contains 174 cases (Cases 197-370). Autopsied 
cases (Cases 197-201) are put first and are followed by cases 
in which lumbar puncture data are available (Cases 202-207) . 
A third group of cases is that in which so-called organic symp- 
toms are much in evidence, either independently or in asso- 
ciation with functional symptoms (Cases 208-219). There 
follows a small group of three cases with shrapnel wound 
(Cases 220-222), in which hysterical symptoms were promi- 
nent, as against the prevalent and correct conception that 
wounded cases are not so prone to psychoneurosis as non- 
wounded cases. Three cases specially marked by tremors 
(Cases 223-225) follow, the last of which gives the victim's 
(a French artist) own account of his feelings. The next two 
cases (Cases 226 and 227) give respectively a German and a 
British soldier's account of Shell-shock symptoms. 

There then follows a great group of cases (Cases 228-273) 
arranged according to the part of the body chiefly affected 
by hysterical symptoms. The arrangement is one of toe to 
top, or as one might more technically say, cephalad. This 
cephalad arrangement naturally begins with cases with symp- 
toms affecting one leg or foot (Cases 228-235). Then fol- 
low cases of paraplegia (Cases 236-241). As we proceed 
cephalad then follow four cases of the so-called hysterical 






EPICRISIS 853 

bent back, or camptocormia (Souques). Then come walk-^ 
ing disorders (Cases 246-248). Still proceeding cephalad, 
disorders of one arm and hand are considered in a series of 
six cases (Cases 249-254). Bilateral phenomena, symmetrical 
or asymmetrical, follow in Cases 255-258. Now reaching 
the head, we deal with cases of deafness (Cases 259-260), of 
deafmutism (Cases 261-263), of speech disorder (Cases 264 
and 265), with two special cases (Cases 266 and 267). Eye 
symptoms are dealt with in a ser es of cases (Cases 268-272), 
and Case 273 deals with crania nerve disorder supposed to 
be due to shell windage without explosion. 

The idea of the above arrangement of 46 cases (Cases 228- 
273) is that the reader dealing with cases of hysterical disorder 
due to physical shell-shock, or some equivalent thereof, may 
inspect the data in a few analogous cases described more or 
less fully in the literature. By reference to the index, the 
reader will be able to find still further cases to illustrate the 
symptom in question. 

The next series of cases (Cases 274-281) are to illustrate 
the contentions of Babinski concerning the elective exaggera- 
tion of reflexes under chloroform, and the conception of 
reflex or physiopathic disorders based thereon — a topic to 
which return is made in Section C on Diagnosis, and elsewhere. 
A small group of cases (Cases 282-285) illustrate the delay 
of Shell-shock and kindred symptoms in certain instances, 
cases that suggest a refractory period of greater length than 
usual, or the interposition of some unusual factor. 

The next group of cases (Cases 286-301) is of special note, 
bringing out what is discussed below, namely, the emphasis, 
reminiscence, or repetition of antebellum phenomena, and 
the picking out of weak spots in the organism by Shell-shock. 
Possibly Cases 302-303 belong in the same group of illustra- 
tions of the driving in of ante-bellum effects. Cases 304 and 
305 are definitively cases in which hereditary instability is a 
factor, whereas Cases 306 and 307 form a foil to these, in that 
the phenomena develop in subjects confidently stated to be 
without hereditary or acquired psychopathic tendency. 

The next series of cases (Cases 308-320) shows peculiar 
phenomena; e.g., monocular diplopia, shell-shock psoriasis, 



854 epicrisis 

synesthesia, puerilism, and the like. Shell-shock equiva- 
lents of various sorts are placed in a group of cases (Cases 
321-325). The next series of cases (Cases 326 to the end of 
this Section: 370) show tendencies to general neurasthenic, 
psychasthenic, and other psychopathic phenomena, rather 
than the more defin te phenomena discussed in the early part 
of this section in the series arranged " cephalad." 

50. Rehearsing more briefly these findings, What is the 
nature of these disorders? The literature is practically unani- 
mous on the point : We have to do merely with the classical 
problem of the neuroses, and when all the data are some day 
united, we shall doubtless know a great deal more about the 
neuroses. 

51. Locus minoris resistentiae. That the process, what- 
ever else it does, is rather apt to pick out pre-existent weak 
spots in the patient (the habitua 1 gastropath becoming sub- 
ject to vomiting; the old stammerer stammering once more 
or even becoming mute; the man always " hit in the legs " 
by exertion, now becoming paraplegic) is obvious. The 
striking instances in which an old cured syphilitic monoplegia, 
or an old hysterical hemichorea, comes back under the in- 
fluence of shell explosion in precisely the limits and with 
precisely the appearance of the former disease, indicate how 
various a factor may be the locus minoris resistentiae. 

52. But, without weak spot, without acquired soil, without 
heredity, we must now erect the hypothesis that, the classical 
neuroses may in some, though certainly a minority of cases, 
afflict normal men. Under the war conditions of investi- 
gation touching the family and personal histories of the men, 
perhaps we should not be too sure of this hypothesis ; but the 
army records w 11 after the war allow us to make or break the 
point forever and thereby throw the clearest light upon the 
vexing problems of industrial medicine, wherein progress in 
general has been so slow on account of the partisanship of 
the corporation and plaintiff's attorneys. 

53. Purely psychogenic war cases exist: Though Shell- 
shock denotes, to say the least, shocks and shells — yet we 
know Shell-shock sans any shock and sans any shell, nay 
sans either shell or shock. 



EPICRISIS 855 

The fact that a soldier may get war dreams though he has_ 
never been in the fighting zone and never by any chance ob- 
served the circumstance of war, or the fact that a man can 
become mute on the second day after a shell explosion be- 
cause the night before he had dreamed of some hysterically 
mute patients in his ward — these facts again, although they 
argue a psychogenic origin for the phenomena of so-called 
" Shell-shock," do not at all mean that actual physical ex- 
plosion in other cases may not be tremendously important. 

54. This is shown by the exceedingly interesting phenom- 
ena of localization or determination of symptoms to a given 
region under the special local influence of the explosion. Thus, 
in the schematic case, an explosion to the left of the soldier 
produces anesthesia and paralysis on the left or exposed side. 
Now and again a case will show such anesthetic and paralytic 
phenomena upon the side exposed to the explosion and some 
hypertonic, irritative phenomena upon the other side. One 
gets the figure in one's mind of an organism fixed, immobile 
and numb, on the spot by the explosion — and the other half 
of the body, as it were, attempting to run away from the 
situation. One side of the body, as it were, plays 'possum, 
the other tends to flight. 

55. Of course these physical phenomena should not blind 
us to the emotional ones. Now and then the multiple causes 
of a case may be analyzed, as, for example, one of blindness in 
which a series of factors emerged, such as excitement, blind- 
ing flashes, fear, disgust and fatigue. I cannot here go 
further into these details, and I need no longer nsist upon the 
fact that surrounding the problem of Shell-shock means 
surrounding the problem of nervous and mental diseases 
as a whole, and that thus to be a Shell-shock analyst means 
to be a neuropsychiatrist. 

56. The organic problems of the nervous system are 
brought up constantly in differential diagnosis, but the 
functional problems divide themselves up in a perturbing 
manner into a fraction properly termed the " psychopathic " 
(that is, after the manner of hysteria), and " non-psycho- 
pathic " (that is, after the manner of reflex disorders of 
Charcot, newly named " physiopathic " by Babinski). 



856 EPICRISIS 

57. For the moment we are not discussing differential 
diagnosis, but are merely trying to circumscribe the features 
we wish to call Shell-shock features : We have concluded to 
call them functional — but what is it to be functional? 

Too simple is the reply: 

Functional = Non-Organic. 
Inaccurate and misleading is the reply 

Functional = Psychic. 
We may more correctly express the situation, pathologi- 
cally speaking, in the following categories (see chart, page 870) : 
jORGANOPATHIC (Lesional, destructive) : 

(a) gross, or (b) microscopic, or perhaps (c) chemical. 
DYNAMOPATHIC (functional, irritative, inhibitory,— 
but reversible ad originem) : 
(a) psychopathic; (b) physiopathic (" reflex ")• 

58. As to the high psychic functions, we had thought of 
them as split in hysteria, in dissociation of personality. And 
we had roughly distinguished these conditions as psycho- 
pathic from conditions we called neuropathic, regarding the 
latter neuropathic disorders as on the model of the effects of 
cutting off or destroying certain necessary neurons. How- 
ever clear or unclear we were as to the nature of the neuro- 
pathic, it does not here matter. Babinski's point is that 
there is another kind of dynamic disease that operates, not 
after the manner of hysteria, but after a manner reminding 
one of the forgotten " reflex " disorders of Charcot — dis- 
orders that fitted the textbooks so poorly that the textbooks 
dropped them out. In short, what you might call the 
dynamopathic or functional in nervous disease has been 
shown to fall into two parts — a psychopathic fraction and 
a non-psychopathic fraction. Babinski calls this non-psy- 
chopathic fraction physiopathic or reflex. And these reflex 
or physiopathic disorders have a different order of curability 
from that of hysterical or psychopathic disorders. By what 
simple device did Babinski prove this? By chloroforming 
the patient. Under chloroform, when all the other reflexes 
were stilled, Babinski could bring out, in relief as it were, 
certain reflexes, or even hypertonuses, that were in the waking 



EPICRISIS 857 

life wholly concealed, — yet at the same time consciousness^ 
in the usual sense of that term, had vanished. Accordingly, 
the proof of a new type of functional disease, at times con- 
cealed by the overlay of higher neurones, was now plain. 
Does not this offer new leads of the greatest value in that 
most intricate of fields, psychopathology? Is not the model 
here offered of diseased nervous functions, non-psychic in 
nature (in the ordinary sense of psychic) but of almost equally 
complex nature: 

Whoever wins the great war from the military point of 
view, there can be no doubt as to what writers contributed 
most from the war data concerning the doctrine of hysteria, 
especially concerning the theoretical delimitation of hysteria 
from other forms of functional nervous disease: There can 
be no other answer than that, in theoretical neurology at least, 
the French have already won the war, if only by means of 
the remarkable concept set up by Babinski of the so-called 
physiopathic (that is, non-neuropathic and non-psycho- 
pathic). 

But how has this splitting of functional neuroses into 
psychopathic and physiopathic been rendered certain? By 
the tremendous modern sharpening of differential diagnosis 
dating from, e.g., the discovery of the Babinski reflex. This 
brings us to the brink of considerations concerning the 
differential diagnostic problem. 

First it may be well to regard the whole problem in the 
light of those mental diseases that we slid over when we were 
delimiting Shell-shock as against syphilis, epilepsy and 
somatic disease. 

59. Why do some authors think of Shell-shock as an 
4 * officer's disease " ? It is clear that they cannot be thinking 
so much of the physiopathic cases as of the psychopathic ones. 
But psychopathic conditions are obviously more readily 
brought about in complex and labile apparatus. This 
point comes out strongly in relation with the comparative 
stability of the feeble-minded, at least of most feeble-minded, 
that get into war relations. 

The possible relations of Shell-shock to feeble-mindedness 
are of some interest. We know that Shell-shock picks out 



858 EPICRISIS 

certain nervous and mental weaklings and indeed that one 
author claims as high a percentage as 74 for war neuroses 
having a hereditary or acquired neuropathic basis. How far 
does feeble-mindedness itself count among these supposedly 
susceptible nervous and mental weaklings? Is a feeble- 
minded person especially in condition for Shell-shock? 

There are rumors of experiments to show that if in an 
aquarium containing some jelly fish alongside bony fishes, 
you explode a substance, the jelly fish ride through unscathed 
whereas the bony fishes are killed by the shock. The jelly 
fish presumably had too simple an organization. 

There is something to be said for the idea that in man also 
the higher and more complex specimens are more susceptible 
to Shell-shock, that is, to the neuroses of war, than are the 
lower and more simple combatants. Some statistics indicate 
that ^officers, who are in the main of a higher and more com- 
plex organization than the private soldiers, are much more 
susceptible than are private soldiers to the neuroses of war. 
Doubtless we shall not be able to verify these statistics until 
long after the war and, so far as I know, no very inclusive 
statistics have been presented. 

On the whole, I judge from the case history literature that 
the feeble-minded, unless they be of that very high level 
sometimes called subnormal, are not particularly susceptible 
to the neuroses. It is obvious that idiots and, for the most 
part, imbeciles, do not get into military service. As for 
what the English term the feeble-minded or what we in 
America are now terming morons, it may well be that our 
draft boards do not always exclude. High French author- 
ities have specifically determined in certain instances that 
the high-grade feeble-minded would be perfectly suitable for 
certain branches of the service. There is the case, for ex- 
ample, of a sandwich man of Paris who somehow got into 
the French army and was being perpetually sent to look for 
the squad's umbrella and the key to the drill ground, but 
sang and swung his gun with joy as he went to the front, and 
apparently did very well there. This man had been a state 
ward and, as you know, well- trained state wards are frequently 
exceedingly good at elementary forms of drill. 



EPICRISIS 859 

Then there is another case of an obvious imbecile who was, 
quite without any idea of military rank and often got pun- 
ished for treating his superiors like his comrades and was the 
butt of his section, but on the firing-line remained cool, care- 
less of danger — a magnificent example to his comrades — 
at last surrounded and taken prisoner. Here the story might 
have ended and the folly of enlisting imbeciles in the army 
might have seemed perfectly plain, except that our imbecile 
forthwith escaped from the Germans, swam the Meuse and 
got back to his regiment! 

Here then are cases in which the slight degree of hypo- 
phrenia — it seems unwise to give it the opprobrious title 
" feeble-mindedness " — would have been entirely incon- 
sistent with the development of Shell-shock. Such men are, 
perhaps, too simple to develop neuroses, On the other hand, 
it would appear that certain of the slight degrees of hypo- 
phrenia, such as we might find in so-called subnormal or 
stupid persons, would prove capable of " catching Shell-shock" 
as it were, and then find themselves entirely incapable of 
rationalizing the situation. In short, there may be a group of 
psychic weaklings, just complex enough to fall into the zone 
of potential neurotics, but just simple enough to render the 
processes of rationalization (or what one author terms autog- 
nosis) and of psychotherapy in general entirely unavailing. 

After the war we may be confronted with a number of 
persons with their edges dulled by the war experiences. One 
has met even brave officers who, after months of furlough, 
still maintain that they will never get back to their normal 
will and initiative. Whether these hypoboulic persons have 
not been reduced to subnormality so as to resemble the 
slighter degrees of hypophrenia or feeble-mindedness can 
hardly be determined now. They will form important prob- 
lems in mental reconstruction, for with the best will in the 
world, the occupation-therapeutist with all her technic, may 
be unable to force or coax the will of such hypoboulics into 
proper action. Nor will the ordinary environment of home 
and neighborhood turn the trick properly. Expert social 
work in adjustment, both of the returned soldier to his en- 
vironment and of the environment to the returned soldier, 



860 EPICRISIS 

may be necessary. I speak of this problem here not because 
these persons are hypophrenic or feeble-minded in the ordi- 
nary sense, but we must constantly bear in mind our experi- 
ence in the teaching of hypophrenics (both in the schools for 
the feeble-minded and in the community) when we are facing 
problems of mental reconstruction. 

60. As for alcoholism, Lepine's figures bespeak its im- 
portance as a hospital -filler and a good deal of prime interest 
surrounding alcoholism has been developed in the war; but 
on the whole, so far as I can determine from the war case 
literature, there is little or no direct relation between alco- 
holism and Shell-shock, despite the fact that in a number of 
instances alcohol has complicated the issue and very possibly 
helped in a general demoralization of the victim. However, 
the alcoholic amnesias and particularly a few instances of the 
so-called pathological intoxication have exhibited a certain 
medicolegal interest, recalling what was just said above about 
the responsibility of a drunken epileptic. Alcohol remains, 
I should say, pending exact monographic work upon this 
topic, purely a contributory factor for the war neuroses. 

It must be that the exigencies of the war have prevented 
full reports of alcoholic cases ; or perhaps they are regarded as 
of such every-day occurrence as not to demand case reports. 
The alcohol and drug group is represented by 1 7 cases (Cases 
86-102). 

The so-called pathological intoxication is illustrated in 
Cases 86 and 87. Case 86 was entirely amnestic for an 
attack of hallucinations in which he tried to transfix comrades 
with a bayonet. Cases 87-97 are cases of disciplinary nature, 
— the majority from a German writer, Kastan. Case 88 
illustrates desertion in alcoholic fugue, and Cases 90-92 are 
three further cases of desertion in alcoholism. 

Cases 94 and 95 give a partial explanation of some German 
atrocities. At J east, here are cases in which the atrocities, 
with attempted murder and rape, are described more or less 
fully in transcripts of medicolegal reports. Case 98 throws 
a curious cross-light upon the war, in that a drunken soldier 
got an unmerited long leave after paying 100 sous for an 
injection of petrol in his hand. Cases 99-102 are cases of 



EPICRISIS 861 

morphinism, illustrating the effects of the war upon the fate^ 
of morphinists. 

61. That war makes nobody go mad in the asylum or lay 
sense of the term has been abundantly proved by the data 
of this war — and this conclusion is of value in our medical 
endeavors to establish a proper lay conception of the nature 
of Shell-shock. Consider first schizophrenia (dementia prae- 
cox). 

That the causes of dementia praecox, still unknown as they 
are, lodge more in the interior of the body or in special in- 
dividual reactions of the victim's mind, seems to be shown by 
the phenomena of this war, since there seems to be no great 
number of dementia praecox cases therein produced. To be 
sure, some schizophrenic subjects do get into the service, and 
sometimes their delusions and hallucinations get their content 
and coloring from the war. Thus a Russian, wounded in the 
army, developed delusions concerning currents running from 
his arm to the German lines and felt that he was, so to say, 
the Jonah of the Russian front, as he could determine shell 
fire to the spot where he was by the arm currents. 

Now and then a case shows a scientifically beautiful ad- 
mixture of ordinary dementia praecox phenomena with the 
effects of shell wound or shock. A picturesque case from the 
standpoint of German psychiatric diagnosis is one of a soldier 
who boxed the ear of a kindly sister who tried to steer him 
from a room where the examination of another patient, a 
woman, was going on. On the whole, the eminent German 
psychiatrist who examined him felt that the case was really 
one of psychopathic constitution, as he had shown somewhat 
similar irascibility on a slight occasion before. However, 
much to the astonishment of all, the patient developed further 
symptoms. His ego got terribly swollen. At last he was 
fain to utter a denunciation of the entire Junkertum and of 
the Kaiser: he said in fact that he was an Inhabitant of the 
World and not of Prussia merely. Over here we allow such 
persons to edit newspapers and write books with impunity, 
but the eminent German psychiatrist, before mentioned, was 
constrained to alter his diagnosis of this cosmopolite from 
psychopathic constitution to dementia praecox! 



862 EPICRISIS 

The group is represented by 16 cases (Cases 147-162). 

62. There are four cases (Cases 148-151) of a disciplinary 
nature. The first (Case 148) was actually arrested as a spy 
because he was making drawings near a petroleum tank. Of 
two cases of desertion, one was due to a fugue of catatonic 
nature (Case 149), and the other (Case 150) was one of 
desertion with behavior suggesting schizophrenia. However, 
this man was determined to be responsible for his act, and 
condemned to 20 years in prison. This latter case might be 
considered also in connection with Group III (the epilepsies), 
Group IV (the pharmacopsychoses) , and possibly Group XI 
(the unresolved psychopathias) . 

Case 151 was likewise alcoholic and disciplinary: the man 
went so far as to keep a cigar in his mouth while the captain 
was rebuking him and was, in fact, an old sanatorium case, 
afflicted with some sort of degenerative disease, presumably 
dementia praecox. 

63. That schizophrenic symptoms may be aggravated by 
service is shown likewise in the case that follows, namely, 
Case 152, a man who had been hearing false voices for some 
two years, had heard his own thoughts, and felt his personality 
changing. The military board decided that the mental 
disease had been aggravated by service. Case 153 might 
offhand be regarded as a malingerer, as he shot himself in 
the hand. Upon military review, a delusional state set in, 
and in the course of no very long time a state of schizophrenic 
apathy. In point of fact, however, this man had already been 
in several hospitals for previous examination, and had served 
in the army in relatively normal intervals. Case 154 is 
that of a dementia praecox who volunteered for three years 
in French infantry but forthwith gave indications of mental 
deterioration. This case of a dementia praecox volunteer 
may be compared with Case 36: that of a superbrave im- 
becile who swam the Meuse, back from a German prison; 
with Case 47, that of the feeble-minded person with an in- 
subordinate desire to remain at the front; with Case 163, 
a maniacal volunteer; and Case 175, a neurasthenic volunteer. 

64. Diagnostic questions are brought up by Cases 155- 
166, in the former of which Bonhoeffer made at first a 



EPICRISIS 863 

diagnosis of some form of psychogenic disease, possibly 
hysterical, but had eventually to alter the diagnosis to hebe- 
phrenia or catatonia. Case 156 was possibly one of Shell- 
shock, though the man remained on duty for a month with 
but one symptom, trembling of the arm. For nine months 
he showed a variety of symptoms apparently consistent with 
the diagnosis hysteria, but then developed catatonic and 
paranoic symptoms clearly warranting the diagnosis dementia 
praecox. 

65. Schizophrenia may not only be aggravated by service, 
but as Case 157 shows, war experience may have a definite 
effect upon the content of hallucinations and delusions. 
Thus, a man wounded in the left shoulder built up the idea 
of currents running from his left arm to the Germans, such 
that if anything were touched by the arm, bombardment of 
the Russians would at once start up. The arm, in short, was 
charmed. 

66. Psychopathic bravery is not shown in the feeble- 
minded only: m Case 158 is that of an Iron Cross winner who, 
after an hysterical-looking attack with hallucinatory reminis- 
cences of a Gurkha whom he had bayoneted, turned out to 
be hebephrenic. Case 159 might at first sight have been 
placed among the encephalopsychoses on account of the 
trauma to the occiput, and in fact the mystical hallucinations 
shown were of a visual nature (a rainbow-colored bird with 
the face of the Holy Virgin). In point of fact, there was 
probably no causal relation between the mystical delusions 
and the brain injury. 

67. Case 156, above mentioned, might perhaps be inter- 
preted as one of Shell-shock dementia praecox, but the in- 
terval of nine months, though filled with hysterical symptoms, 
is decidedly long in which to suppose that shell-shock factors 
could be in process of causing dementia praecox. Cases 
160 and 161 are more suspicious. Six German soldiers were 
killed by a German shell within the zone of German fire, two 
steps away from the subaltern officer (Case 160), who carried 
on for some hours, made his report duly, but thereafter de- 
veloped tremors and lost consciousness. According to Wey- 
gandt, the case is one suggestive of dementia praecox, but 



864 epicrisis 

very possibly should be regarded as one of psychoneurosis. 
At all events, it would be dangerous to found a doctrine to 
the effect that dementia praecox can be initiated by shell- 
shock upon such a case as 160. Case 161 is similarly doubt- 
ful. There are a number of symptoms in this man (the sole 
survivor of an explosion in a blockhouse) consistent with the 
diagnosis Shell-shock, and a number of others which hardly 
can be given any other interpretation than that of catatonic 
dementia praecox. But the available medical data do not 
begin until five months after the shell explosion. We must 
conclude here also that no definite evidence exists that 
dementia praecox can be initiated by the physical factor 
shell-shock. Case 162 is one in which there are shell-shock 
factors and fatigue factors in a man who had once ante- 
bellum shown signs of mental disorder, and who developed 
delusions subsequent to a fugue following shell-shock. The 
most one could make of this case would be to say that a latent 
schizophrenia had been liberated by shell-shock. 

68. To sum up concerning the schizophrenias (dementia 
praecox group) , there are cases of great disciplinary interest 
in which alleged espionage and desertion turn out actually 
to be schizophrenic phenomena. Again, there are interesting 
diagnostic problems in the differential diagnosis of hysteria 
and catatonia. There is evidence that experience in the war 
may be woven into the hallucinatory and delusional contents 
of cases of pre-existent psychosis. 

69. As to the important question whether shell-shock can 
initiate dementia praecox, the evidence from these reported 
cases is against the hypothesis; but if the query be, whether 
Shell-shock might not aggravate dementia praecox, it may 
be stated that a military board has decided that dementia 
praecox may be aggravated by some forms of military service. 
There is no reason to suppose that shell-shock factors might 
not operate in this way. Cases 152 and 162 will be of ser- 
vice in the proof of this contention; and Case 162 seems to 
be definitely one in which a latent schizophrenia, showing 
itself in one ante-bellum attack, was liberated once more 
after shell-shock. Of course, the plan of this book and the 
method of choice of its cases precludes any statistical con- 






EPICRISIS 865 

elusions of great weight from the relative number of cases 
found in the different groups; and it might well happen that 
psychiatrists would not report cases of an everyday and com- 
monplace nature which might yet be very frequent. On the 
whole, however, it would not appear that dementia praecox 
is at all a frequent phenomenon in the war. 

70. Nor can the cyclothymias (manic-depressive psychoses) 
be charged up to war factors to any important extent. 

On account of the somewhat close resemblance between the 
phenomenon of manic-depressive psychosis and what we 
ordinarily feel ourselves — a logical situation reflecting merely 
the fact that the phenomena of over- activity (mania) and 
of under-activity (depression) are merely quantitative vari- 
ations from the normal — it might be supposed that the war 
life and its shock and strain would start up the cyclothymias 
in some numbers. Why should not a shell explosion start up 
a mania or throw a man into a depression? In point of fact 
the literature somehow does not agree with this presupposition. 

Some years ago in Massachusetts a brief investigation was 
made of the assigned causes of the successive attacks in a 
great number of cyclothymic (manic-depressive) cases, and it 
was found that each successive attack progressively had less 
of the physical in the previous history. Something like 45% 
of all the first attacks had a pretty obvious cause in the 
soma, such as a kidney disease, a heart disease, a puerperal 
condition and the like, but the second attacks failed to show 
even 20% of such obvious somatic causes, and the third 
attacks even less than 10%, and so on. 

Now war conditions and even the shell explosions them- 
selves have apparently not set up any such conditions as 
those of mania or of depression. Most of the instances of 
cyclothymia are instances of men who are cyclothymic before 
they enter the army. These experiences, when after the 
war we can sift them all out, may allow us to form better ideas 
as to the etiology of many of the psychoses, and the great war 
may thus prove a gigantic experimental reagent which will aid 
in solving some of the major problems of mental hygiene. 

71. The cyclothymic or manic-depressive group is repre- 
sented in strikingly few cases, seven in number (Cases 163- 



866 epicrisis 

169). One of the ideas in the literature concerning the 
manic-depressive group has been that it is very possibly re- 
motely allied to Graves' disease, a hypothesis upheld by 
Stransky in Aschaffenburg's Handbook. Hyperthyroidism 
itself has been, of course, a rather striking feature in the fore- 
ground or background of many sick patients in the war. 
However, war factors have proved able to bring out very 
few instances of cyclothymic (manic-depressive) disease. 
Amongst our seven cases, the first (Case 163) was that of a 
maniacal Alsatian of 59 years, who volunteered because of 
his hypomania. Case 165, the case of a German who pelted 
French trenches with apples from an appletree in No Man's 
Land, was another case in which the war had little or nothing 
to do with the development of the mania. One of fugue 
(Case 164) was a case of melancholia and anxiety not closely 
related with war experience. In three further cases trench 
life and war stress may be thought to have liberated the 
cyclothymic phenomena. Case 166 was that of a man of 38, 
previously referred to, who developed arteriosclerosis and 
whose depression and hallucinations had followed four months 
of trench life devoid of battles or injury. It is possible that 
this case should be regarded rather as syphilitic or of some 
unknown organic origin. At all events, it is not clear that 
it could be made to bear a heavy weight of hypothesis con- 
cerning the genesis of cyclothymic psychoses. Case 167, a 
naval officer who distinguished himself greatly by work on 
land in Belgium, was regarded by its reporter as one of 
manic-depressive psychosis with the fatigue of war as its 
base. It might be queried whether the man's distinguished 
work was not due to an early phase of hypomania, after which 
the cyclothymic effects began. In Case 168 there was some 
evidence of the effect of war stress, as certain hallucinations 
grew more intense after the bombardment of Dunkirk; but 
in point of fact, this man had shown a predisposition and in- 
deed a period of so-called neurasthenia ante-bellum. It is 
doubtful, therefore, whether there is any case here abstracted 
which can be used to support the hypothesis that the manic- 
depressive (cyclothymic) group of mental diseases has had or 
is likely to have its genesis in war stress. The remaining 



EPICRISIS 867 

case (Case 169) is one illustrating a method of treating low 
blood pressure in depression. 

To sum up concerning the cyclothymias : War stress seems 
to have had singularly little effect in the production of fresh 
attacks, and so far as we are aware, no effect in starting up a 
manic-depressive diathesis, unless Case 167, — that of the 
naval officer who distinguished himself in land battles, — 
looks in that direction. It is, of course, to be conceded that 
hypomania might readily be overlooked under war conditions, 
and that suicidal melancholias, belonging in this group, might 
be interpreted as natural war-made depressions. Very pos- 
sibly, therefore, this result (running to the effect that the 
cyclothymic forms of mental disease are rare in military life) 
may need revision. 

72. Summary of general considerations concerning the 
nature of the Shell-shock neuroses (paragraphs 40-71). 

Having (a) roughly delimited the Shell-shock neuroses 
from syphilis, epilepsy, and somatic disease, we inquired 

(b) What, after all, are functional neuroses? We re- 
mained dissatisfied with a definition by negatives. But we 
found that 

(c) practically the problem seemed to reduce to telling the 
organic apart from the functional and we found that 

(d) in almost all cases we have to raise the hypothesis 
of the organic. Also that 

(e) the absence of external injury is no guarantee against 
the existence of internal injury. Also that 

(/) cases are frequent enough in which organic and func- 
tional phenomena are combined. Also that 

(g) essentially functional cases may be peritraumatic or 
metatraumatic (in the sense of Charcot's hysterotraumatism). 
But 

(h) the statistical majority of cases remains essentially 
functional. 

(i) We then looked over a series of cases developing in- 
cidentally in the war and 

(j) we compared these with the war cases, the latter 
arranged cephalad. 



868 



TREATMENT AND RESULTS 






DIAGNOSTIC ALLIANCES OF THE SHELL- 
SHOCK NEUROSES 



SCHIZOPHRENIA 
CYCLOTHYMIA 
MORONITY 
ALCOHOLISM 



SHELL 
SHOCK 

NEUROSES 



NEUROSYPHILIS 

EPILEPSY 

SOMATOPATHY 



Note arrow lengths: Practically we find shell-shock neuroses very dif- 
ferent from certain functional (or but mildly organic) disorders and not 
so different from certain seriously organic disorders. 



SCHIZOPHRENIA 
CYCLOTHYMIA 
MORONITY 
ALCOHOLISM- 



SHELL 

SHOCK 

NEUROSES 



NEUROSYPHILIS 

EPILEPSY 

SOMATOPATHY 



Note arrow lengths: Theoretically, shell-shock neuroses, being presum- 
ably in large part functional, ought to ally themselves more closely with 
the left-hand group than with the right-hand group. But they do not! 

In short, these functional diseases are not so hard to distinguish from 
various other functional diseases as they are from certain organic diseases. 
The most serious diagnostic problem is between the war neuroses and 
organic brain disorders. 



Chart 17 



TREATMENT AND RESULTS 



869 



LOGICAL PLACE OF THE "REFLEX" DISORDERS 
(OF BABINSKI-FROMENT) 



e.<2. neurosyphilis paretica 



ORGANO- 
PSYCHOPATHIC 



Hysteria e,d 



DYNAMO - 
PSYCHOPATHIC 



ORGANO- 
NEUROPATHIC 



/ 



DYNAMO- 
NEUROPATHIC 



Babinski's "reflex." \ 
e.g. neurosyphilis labefcica or physiopathic disorders ejjf. 

A frequent error of neurologists has been to identify " functional " with 
"psychic " when it came to a question of the classical functional neuroses. 
The above diagram indicates that " functional " contains more than 
"psychic." Doubtless much that goes under the name "unconscious" 
belongs in the right lower quadrant of this diagram. See discussion in 
text. 



Chart 18 



870 EPICRISIS 

(k) We found many war cases showing emphasis, reminis- 
cence, or repetition of ante-bellum phenomena (weak spots, 
locus minoris resistentiae, imitation), but 

(J) we also found that perfectly sound untainted men could 
succumb to Shell-shock neurosis. 

(m) We found a few purely psychogenic cases without 
sign or suspicion of physical shock. 

(n) We studied the localization (traumatotropic) group. 

(o) We arrived, with the aid of Babinski, at the necessity 
of splitting functional cases into psychopathic and physio- 
pathic. 

73. Summary of general considerations : continued. 

We found ourselves looking on the Shell-shock neuroses as, 
like other functional neuroses, in a sense mental diseases. 
Perhaps we would better say (to get rid of all suspicion of 
medicolegal " insanity ") that the Shell-shock neuroses seemed 
to us in some sense psychopathic. But, though the Shell- 
shock neuroses looked psychopathic and were presumably 
more functional than organic in nature, it was a curious thing 
that, practically speaking, the Shell-shock neuroses proved to 
be farther away from the more functional of the psychoses 
than from certain organic psychosis. 

In particular, we found reliable authors insisting on the 
practical diagnostic necessity of excluding syphilis, epilepsy, 
somatic disease — whereas the nature and causes of the Shell- 
shock neurosis seemed theoretically to withdraw them most 
remotely from that triad of mainly organic disorders. By the 
same token, theoretically one might have supposed these 
Shell-shock neuroses to draw very near to those far less 
organic disorders (schizophrenia, cyclothymia, feeble-minded- 
ness {i.e., the slighter degrees likely to be found in military 
service, alcoholism) — yet practically few large diagnostic 
problems came to light as between the Shell-shock neuroses 
and the tetrad of dynamic or lightly organic diseases above 
listed. 

74. Diagrammatically this situation is presented in 
Chart 17. 

But why should the Shell-shock neuroses seem so " or- 
ganic"? Partly, it is probable, because the term " organic " 



EPICRISIS' 871 

/ 

is too often used to mean " subcortical." In another dia- 
gram the truer relations are depicted, with four classes of 
phenomena (Chart 18). 

(a) Organic mental (cortical), e.g., general paresis. 

(b) Functional mental (cortical), e.g., hysteria. 

(c) Organic neural (subcortical), e.g., tabes dorsalis. 

(d) Functional neural (subcortical), e.g., " reflex" disorders. 



Diagnostic Differentiation Problem 

75. Having disposed of the problem of the rougher De- 
limitation of the Shell-shock neuroses, we approach the 
problem of their finer Differentiation. For the sake of 
the present argument we propose to regard the Shell-shock 
neuroses as essentially Dynamopathic, i.e., functional 
whether in the ordinary mind-born (psychogenic) sense of 
classical hysteria or in the modern nerve-born (neurogenic) 
sense of Babinski. The problem of this differentiation will 
accordingly be that between the dynamopathic and the 
organopathic. 

In the orderly diagnosis of mental disease, from the stand- 
point of the major orders or groups, we ordinarily come at 
this point to the focal brain diseases. In analyzing the neuro- 
psychiatry problem of a so-called Shell-shocker, it is, of 
course, our bounden duty to exclude syphilis. Even though 
the percentage of syphilitic victims of Shell-shock is not high, 
yet these cases promise so much from treatment that they 
deserve to get their diagnosis as early as possible, and the 
English workers who have worked most in the syphilitic 
field insist upon this point. 

We next proceed, as above indicated, to the elimination of 
hypophrenia with all the various grades of feeble-minded- 
ness. Thirdly, we try to exclude the various forms of epi- 
lepsy; and fourthly, the effects of alcohol, drugs and poisons. 

In ordinary civilian practice, such as that at the Psycho- 
pathic Hospital, the orderly elimination for diagnostic pur- 
poses of the great groups of the syphilitic, hypophrenic 
(feeble-minded), epileptic and alcoholic, leaves us with cases 
in which there either is or is not important evidence of or- 



872 EPICRISIS 

ganic nervous-system disease, such as that shown in cases 
with heightened intracranial pressure or in cases with asym- 
metry of reflexes and other forms of parareflexia. In mili- 
tary practice these logical questions of prior elimination of 
syphilis, feeble-mindedness, epilepsy, and alcoholism must go 
a-glimmering at first, unless their signs are so obvious as to 
permit diagnosis by inspection. 

76. But the nervous and mental cases almost one and all 
give rise to the suspicion at least of organic disease, possibly 
traumatic in origin. Even when a man falls to the ground 
without a scratch upon his skin, there is some question 
whether in his fall he has not sustained some slight intra- 
cranial hemorrhage which the lumbar puncture fluid might 
show. Add to this that the signs of hysteria are very often 
unilateral, and it will readily be conceived how much like an 
organic case an hysteric in the casualty clearing station may 
look. Rapid decision may be necessary in order to get im- 
mediate effects in psychotherapy a few minutes or hours after 
the shell explosion, and one may need to choose between 
applying a possibly unsuccessful psychotherapy forthwith and 
making a thorough neurological examination. As Babinski 
has pointed out, making a thorough neurological examination 
gives opportunity for all sorts of medical suggestion to be 
conveyed to the patient. It would appear that many an 
hysterical anesthesia has been given to a patient by the very 
suggestion of the physician testing sensation. Here one does 
not refer to malingering in the conscious and designed sense 
of the term, but to the operation of some genuinely psycho- 
pathic, that is to say, hysterical process. 

77. In the case of head injury, naturally the majority of 
nerve phenomena will ordinarily be upon the opposite side 
of the body to the side of the head that is injured. The 
reverse situation holds for hysterical cases, wherein it would 
appear that the bursting of a shell, let us say upon the left 
side of the body, seems to determine contractures, paralyses 
and anesthesias to that same left side of the body; now and 
then complicated cases appear which put the neurologist 
through his best paces. Such a case is that of a man who was 
wounded on the left side of the head and promptly developed 



EPICRISIS 873 

a hemiplegia on the same (left) side, with aphasia. Now 
aphasia ought to be the result of a lesion on the left side of 
the brain in the common run of cases, whereas left-sided hemi- 
plegia ought to be the result of lesion on the right side of the 
brain. In point of fact, the analyst of this case felt that he 
was dealing with a direct injury on the left side of the brain, 
leading to aphasia, and a lesion by contrecoup on the right 
side of the brain, leading to a left-sided hemiplegia. 

It is not only at the casualty clearing stations and along 
the lines of communication that the difficulties in telling 
Shell-shock in the neurotic sense from traumatic psychosis 
and the effects of focal brain lesions are found, since the lit- 
erature amply shows that diagnostic problems remain open for 
weeks or months in the various institutions of the interior, 
to which all the belligerents have been forced to send their 
cases. 

78. A glance at the differential tables that have been de- 
veloped, for example, by the French neurologists, will show 
how fine the diagnosis betwixt a hysterical and an organic 
disease may be, especially when we consider how often there 
are admixtures of the two. The rule holds for the vast ma- 
jority of cases that absolute bullet wounds or shrapnel 
wounds do not produce Shell-shock ; and the statistical story 
is so clear that one might almost think of the wounds as in 
some sense protective against shock, that is, gainst Shell- 
shock, not against traumatic or surgical shock. Neverthe- 
less, by some process whose nature is obscure, the hysteric is 
apt to pick up some slight wound and, as it were, surround 
this wound with hysterical anesthesia, hyperesthesia, paraly- 
sis or contractures. 

The chances are, if we should collect all our civilian cases 
of Railway Spine and of industrial accident with traumatic 
neuroses, we should be able to prove this same strange rela- 
tion between slight wound in a particular part of the body 
and the local determination of hysterical symptoms to that 
region. Of course, the determination follows no known laws 
of nerve distribution to skin or muscles, and the effect is 
apparently a psychopathic or, at all events, a dynamic proc- 
ess without clear relations to the accepted landmarks. 



874 epicrisis 

I do not mean to suggest, that aside from the hurry of war, 
the differential diagnoses here are more difficult than those 
in civilian practice; but the difficulties are at least as great 
as those that have faced the civilian practitioner. What 
needs emphasis is that just because we have concluded that 
the statistical majority of the cases of so-called Shell-shock 
belongs in the division of the neuroses, we should not feel 
too cock-sure that a given case of alleged Shell-shock appearing 
in the war zone or behind it is necessarily a case of neurosis. 

After the early " period of election " for psychotherapy 
in the war zone has passed, there can be no excuse except 
general war conditions for not according to every case of 
alleged Shell-shock a complete neuropsychiatric examination, 
having due regard to the ideas of Babinski concerning medical 
suggestion of new increments and appendices to the original 
hysteria, developed in battle or shortly thereafter. 

We have, however, been able to find in the literature good 
instances of puzzling diagnosis in which such conditions are 
in evidence as acute meningitis of various forms, hydrophobia, 
tetanus, and the like. 

Especially in the diagnosis against Shell-shock hysterias 
we may need to think of the abnormal forms of tetanus, to 
which an entire book in the Collection Horizon has been de- 
voted. The differential diagnostic tables here draw up dis- 
tinctions between local tetanus, involving, let us say, the con- 
tracture of one arm, as against a hysterical monoplegia. 

79. The focal brain group of psychoses here termed en- 
cephalopsychoses, is illustrated by a comparatively short 
series of cases, 16 in number (Cases 103-117). Many more 
cases of this group are presented in Section B, On the Nature 
and Causes of Shell-shock. The motive here is to show 
sundry effects of focal brain lesions produced in the war and 
not related with shell-shock. Case 103 was the curious case 
(see above) of aphasia with hemiplegia — not upon the right 
side, but upon the left side. There had been a wound in 
the left parietal region, and the aphasia was presumably con- 
sequent upon a direct affection of the left hemisphere. On 
the other hand, the left-sided hemiplegia may probably be 
regarded as due to lesions on the right side of the brain pro- 



EPICRISIS 875 

duced by contrecoup. The case not only has surgical im- 
plications and suggestions of importance, but also it throws 
some light on the possibilities in concussion of minor degree. 
As the cases in Section B (On the Nature and Causes ot Shell- 
shock) show, shell-shock, the physical factor, is apt to pro- 
duce anesthesia and paralysis or contracture on the side ex- 
posed to the shell-shock. The means by which these symp- 
toms ipsilateral with the shock are produced is commonly 
thought to be the " hysterical mechanism," whatever that 
may be. Lhermitte, however, suggests that in some cases 
such phenomena might be due to an actual brain jarring with 
contrecoup effects. However, it must be granted that Case 
103 did not come to autopsy. 

80. Case 104 might perhaps better be considered in the 
section on alcoholism, since a gun-shot wound of the head 
may be regarded as having produced intolerance of alcohol 
in the classical manner, similar to that described in Case 
97, wherein, however, the trauma was ante-bellum. Pe- 
culiar crises associated with cortical blindness, vertigo, and 
hallucinations, characterized a case of brain trauma by bullet 
(Case 105). Case 106 is that of a Tunisian, who before the 
war had had a number of theopathic traits with mystical 
hallucinations, but after a gun-shot wound of the occiput 
developed lilliputian hallucinations and micromegalopsia. 

81. Cases 107-112 are cases of infection or probable in- 
fection. Cases 107 and 108 are instances of meningococcus 
meningitis, the second of which appears to have followed 
shell-shock (?). Case 107 led to psychosis with dementia. 
Case 109 developed a meningitic syndrome, which followed 
shell explosion a metre away, the syndrome lasting 14 months. 
The spinal puncture fluid was several times found to contain 
blood. There was apparently no infection of the fluid as in 
Case 112. Possibly Case 109 should be set down as an un- 
usual example of shell-shock psychosis, chiefly dependent 
upon meningeal hemorrhage. 

82. A syphilitic (Case no) in which appropriate tests were 
made and found positive, showed at autopsy a yellowish 
abscess or area of softening in the right hemisphere. The 
curious point about this case was that the only neurological 



876 EPICRISIS 

phenomenon in the case was the absence of knee-jerks in the 
early part of the day; later in the day, they would appear 
once more. Possibly Case in, a case of somewhat doubtful 
nature but presumably of organic hemiplegia, ought to be 
aligned more with the group of cases illustrating the nature 
and causes of Shell-shock. The case was not one with the 
physical factor shell-shock, since the phenomena began ten 
days after a serene convalescence following an operation for 
chronic appendicitis. Perhaps the case was one of organic 
lesion grafted upon a neurosis. 

83. Case 112 is the one noted above of infection of the 
spinal fluid. It is the only case of infected meningeal hemor- 
rhage observed by Guillain and Barre in a wide experience. 
As a rule, these hemorrhages remain aseptic and have a 
favorable prognosis. The organism cultivated from the spinal 
fluid proved to be the pneumococcus. Case 113 yielded a 
somewhat remarkable phenomenon and perhaps would be 
more logically considered in relation with the series of cases 
in Section B that show the picking up of ante-bellum weak 
spots (Cases 287-301); for this subject had had two serious 
affections of the brain ante-bellum. He had had a poli- 
myelitis at five, affecting the left leg, and he had had a right 
hemiplegia with aphasia following pneumonia, at 20. He 
was struck (but apparently not wounded) by shrapnel on the 
right shoulder, and developed athetotic movements of the 
right hand, as well as a general weakness of the left leg. In 
this case, according to Batten, the stress had been sufficient 
to bring into prominence symptoms due to an old cerebral 
lesion. Whether the mechanism in this case is hysterical is 
doubtful. 

84. That not every case of hemianesthesia is hysterical is 
suggested by Case 114, in which the diagnosis of hysteria 
was actually made; but the diagnosis was soon rendered 
doubtful by the fact that there was no evidence of autosug- 
gestion or heterosuggestion. Other phenomena make a 
diagnosis of thalamic hemianesthesia more likely. 

85. Although Shell-shock is not the subject of this section, 
yet a case of syndrome strongly suggesting multiple sclerosis 
is here inserted, following shell-shock (Case 115). The 



EPICRISIS 



877 



co-existence of hysterical and organic symptoms is illus- 
trated in Case 116, one of mine explosion, and Case 117, one 
of injury to back. Case 116 somewhat resembled another 
case of Smyly (Case 219). 

86. Differential Diagnosis between Organic and Hysteric 
Hemiplegia. Babinski, 1900. 



Organic Hemiplegia 
Paralysis unilateral. 



2. Paralysis not symptomatic, e.g., 
in unilateral facial paresis, the 
paresis occurs also when bilateral 
synergic movements are being per- 
formed. 



3. Paralysis affects voluntary, con- 
scious, and unconscious or sub-con- 
scious movements; hence, (a) pla- 
tysma sign,* (b) sign of combined 
flexion of thigh and trunk, and 
(c) absence of active balancing arm 
movements in walking contrasted 
with exaggeration of passive bal- 
ancing movements (limb inert on 
sudden turn of body). 

4. Tongue usually slightly deviated 
to the paralyzed side. 

5. Hypertonicity of muscles, espe- 
cially at first. The buccal com- 
missure may be lowered, the eye- 
brow lowered; there may be exag- 
gerated flexion of the forearm, and 
the sign of pronation may occur 
(hand left to itself lies in pronation). 

6. Tendon and bone reflexes often 
disturbed at the beginning, either 
absent, weakened, or exaggerated 
(almost always exaggerated.) In 
many cases, there is epileptoid trepi- 
dation of the foot. 



Hysterical Hemiplegia 

1. Paralysis not always unilateral; 
especially facial paralysis, usually 
bilateral. 

2. Paralysis sometimes symptomatic; 
facial paralysis almost always symp- 
tomatic. With complete unilateral 
paralysis, the muscles of the para- 
lyzed side may function normally 
during the performance of bilateral 
synergic movements. 

3. Voluntary, unconscious, or sub- 
conscious movements not disordered. 
Absence of platysma sign and com- 
bined flexion of thigh and trunk. 
The active balance movements of 
arm may be lacking but there is no 
exaggeration of passive balance 
movements. 



4. Tongue sometimes slightly devi- 
ated to the paralyzed side; but 
sometimes contralateral deviation. 

5. No hypertonicity of muscles. If 
facial asymmetry exists, it is due 
to spasm. No exaggerated flexion 
of forearm, and no pronation sign. 



6. No alteration of tendon or bone 
reflexes. No trepidation of the 
foot. 



* More energetic contraction of platysma on healthy side when mouth is 
opened or when head is flexed against resistance. 



878 



EPICRISIS 



7. Skin reflexes usually disordered. 
Abdominal and cremasteric reflexes, 
especially at first, weakened or 
abolished. On stimulation of sole, 
toes, and especially the great toe, 
are extended on the metatarsals. 
Babinski toe reflex. Extension of 
great toe often associated with 
abduction of other toes (fan sign). 
Sometimes exaggeration of reflexes 
of defence. 

8. Contracture characteristic and non- 
reproducible by voluntary contrac- 
tions. The hand-grip yields a sen- 
sation of elastic resistance, auto- 
matically accentuated on passive 
extension of the hand. 

9. Evolution of diseased regular con- 
tracture follows flaccidity. When 
regression of disorder occurs, it is 
progressive. 

Paralysis not subject to ups and 
downs (motor defect fixed). 



7. No disturbance of skin reflexes. 
Abdominal and cremasteric reflexes 
normal. Babinski toe reflex and fan 
sign absent. Defense reflexes not 
exaggerated. 



The contracture can be reproduced 
by voluntary contractions. 



Evolution of disease capricious. 
Paralysis may remain indefinitely 
flaccid or may be spastic from the 
beginning. Spastic phenomena may 
sometimes be associated (particu- 
larly in the face) with characteris- 
tic phenomena. 

The disorder may get better and 
worse alternately several times, alter 
rapidly in intensity, and present 
transitory remissions which may 
last even but a few moments (mo- 
tor defect variable). 

87. Differential between Reflex (Physiopathic) Contrac- 
ture and Paralysis, and Hysterical Contracture and Paralysis. 
Babinski, 191 7. 

Hysterical 
1. Paralysis usually extensive but 
superficial and transient if treated. 



Reflex 

1. Paralysis usually limited but severe 
and obstinate even when methodi- 
cally treated. 

2. In the hypertonic forms attitude 
of the limb does not correspond to 
any natural attitude. 

3. Amyotrophy marked and of rapid 
development. 



4. Vasomotor and thermic disorder 
often very marked, accompanied by 
an often very pronounced reduction 
in amplitude of oscillations measured 
by oscillometer. 



2. The hysterical contracture as a 
rule resembles a natural attitude 
fixed. 

3. Amyotrophy, as a rule, absent, 
even when the paralysis is of long 
standing. If existent, it is not 
marked. 

4. There may be thermo-asymmetry 
but it is slight. There are no very 
characteristic vasomotor disorders 
nor modifications in amplitude of 
oscillations. 



EPICRISIS 879 

5. Sometimes very marked hyper- 5. No sharply defined hyperidrosis. 
idrosis. 

6. Tendon reflexes often exaggerated. 6. No modifications of tendon re- 

flexes. 

7. Hypotonia sometimes very well 7. Hypotonia absent, 
marked, and in arm paralysis main 

ballante. 

8. Mechanical over excitability of 8. Over-excitability of muscles absent, 
muscles, often accompanied by slow 

response (?). 

9. Fibrotendinous retractions of rapid 9. No retractions even if paralysis is 
development except in the rare com- of long duration. 

pletely flaccid forms. 

10. Trophic disorders of bone, de- 10. No trophic disorders, 
calcification of the hairs and of the 

phaneres. 

88. The section on Shell-shock diagnosis contains 102 
cases (Cases 371-472). These cases differ in no respect from 
those of Section B except that many of them are more puzz- 
ling and dubious and have been presented by their reporters 
more from the standpoint of diagnosis than from that of 
etiology or therapeutics. In general arrangement, the cases 
roughly correspond to those of Section B. First are four 
cases illustrating the value of lumbar puncture data (Cases 
371-374). There follow cases with either a mixture of or- 
ganic and functional symptoms, or such a constellation of 
symptoms as might readily lead to erroneous diagnosis 
(Cases 375-381). Retention and incontinence of urine after 
shell-shock are illustrated in Cases 382-384. Crural mono- 
plegia, monocontractures, and other affections of one leg 
are shown in Cases 385-392 ; but these monocrural cases are 
in many respects peculiar or even unique as compared with 
the monocrural cases of Section B. Peculiar paraplegias or 
spasms affecting both legs are found in the series 393-395. 
Then follow (Cases 396-400) other cases of doubtful spinal 
cord lesion or shock, including several with dysbasia. Camp- 
tocormia, astasia-abasia and abdominothoracic contracture 
are found respectively in 401, 402, and 403. Affections of 
one arm follow (Cases 404-409) . An assortment of peculiar 
cases in which the differentiation between hysteria and 



88o EPICRISIS 

structural disease is in question, is found in Cases 410-415. 
Peripheral nerve injuries of a sort which might be confused 
with Shell-shock phenomena, including one of light tetanus, 
are considered in Cases 416-419. A variety of cases bearing 
upon the question of the reflex or physiopathic disorders of 
Babinski is found in the series of Cases 420-432. Peculiar 
eye phenomena are presented by Cases 433-438; and cases 
of otological interest are 439 and 440. Epileptoid, obsessive, 
fugue, and amnestic phenomena follow in Cases 441-450; 
451 and 452 are cases of soldier's heart. The simulation 
question is presented in a series of 20 cases (Cases 453-472). 



General Nature of Shell-shock 

89. We are now ready to consider in how far Shell-shock * 
is a distinctive disease. The physical event, shell-shock* we 
have seen at work in most of the major groups of mental 
disease and in some groups of nervous disease. Shell-shock, 
the physical event, has started up a " Shell-shock " paresis, 
a "Shell-shock" epilepsy, a " Shell-shock " Graves' disease, 
a " Shell-shock " dementia praecox, wherein the term " Shell- 
shock " is merely a more specific term than the term 
" traumatic." The physical event, shell-shock, has in special 
ways also changed the responses of the feeble-minded, the 
alcoholic, the cyclothymic, and the psychopathic person of 
whatever ill -defined sort may get into military service. 

The physical event, shell-shock, has likewise caused focal 
irritative and destructive brain disease, spinal cord disease, 
peripheral nerve disease; and many well-recognized species 
of the so-called " organic " diseases of the nervous system 
have been produced. Shell-shock " organic " diseases have 
proved as difficult to tell from all sorts of Shell-shock " func- 
tional " diseases as ever have been the organic and functional 
analogues of these diseases in peace practice. 



* I capitalize Shell-shock here (as elsewhere) to indicate 
the name of a supposed disease entity and leave shell-shock 
without an initial capital to indicate the physical event. 



EPICRISIS 88 1 

But, besides (a) sharing in the cause of mental and nervdus 
disease (in the sense of " Shell-shock " general paresis and 
" Shell-shock " tabes, wherein at least one other factor, viz. 
the spirochete, is known to be at work) and (b) producing 
mental and nervous disease by killing or weakening or sensi- 
tizing neurones in the classical manner of the " focal " lesion, 
the physical event, Shell-shock, (c) appears able to bring out 
the subtler diseases and dispositions of mind which we term 
psychoneuroses, that is, hysteria, neurasthenia, psychasthenia. 
Just as we have for years spoken of " traumatic " psychoneu- 
roses, so we may now speak of " Shell-shock " psychoneuroses 

— nor should anyone believe we cheat ourselves with the 
idea that the adjective "Shell-shock" has helped us more re 
genesis than the adjective " traumatic." " Shell-shock hy- 
steria " and " traumatic hysteria " are on precisely the same 

— slippery — footing in the matter of their origin. The 
physics and chemistry of the psychoneuroses remain in Egyp- 
tian darkness. 

The physical event, shell-shock, then, as the common man 
might say, affects body, brain, and mind in a great number of 
familiar ways; and these familiar ways remain as plain or 
as blind as the neuropathology and the psychopathology of 
today leave them. If thunderstorms and earthquakes got 
suddenly more frequent, we should have numbers of " light- 
ning neuroses " and " earthquake hysterias," neither of 
which would render the physics and chemistry of the psycho- 
neuroses immediately a whit clearer. 

When the common man speaks of some one as suffering 
from lightning stroke or earthquake, he is entitled to be met 
halfway by his hearer, who readily understands that the 
victim is suffering some sort of transient or permanent effects 
of the stroke or quake. In a like common sense should the 
term shell-shock be taken. Stroke, quake, or shock, each 
physical event is recognized as a factor in the situation. An 
event has become a factor. A condition for which the noun 
" shell-shock " was descriptive, in the present tense of some 
event, has passed into history; and the adjective " shell- 
shock " is now explanatory of the past cause, or one of the 
past causes, of a new situation. Shell-shock, the physical 



882 EPICRISIS 

event, takes part in a great number of pathological events 
and as such lapses from noun to adjective. 

But what are these pathological events, viz., the conditions 
of disease, that supervene? So far, in our consideration ot 
psychoses incidental in the war, we have found Shell-shock 
varieties, perhaps, of mental disease; again, possibly a few 
Shell-shock species, using both these terms, variety and 
species, in a quasi botanical or zoological sense. But in 
either instance we do not rise, under the ordinary principles 
of nomenclature, beyond the adjective: Is there any evidence 
that shell-shock, the physical happening, has issued in a 
pathological event of greater dignity, namely, a genus of 
disease? Can shell-shock rise to the dignity of a proper 
noun, Shell-shock, so that we might think of e.g., a new genus 
of the psychoneuroses, something coordinate with hysteria, 
neurasthenia, psychasthenia? None, I believe, has the 
hardihood to propose a new genus of mental or nervous 
disease for Shell-shock regarded as a pathological event. 
A fortiori, it is unheard-of to think of Shell-shock, the patho- 
logical event, as representing a new order of such events, 
coordinate with the psychoneuroses or the epilepsies, for 
example. 

Shell-shock, the pathological event, we conclude, is a variety 
or a species, hardly a genus or an order of mental or nervous 
diseases. If we can keep in mind the obvious distinction 
between shell-shock, the physical event, and Shell-shock, the 
pathological event, we shall save ourselves much trouble. 
And if we can apply the ordinary criteria for the differentiation 
of the great groups (or orders) and the lesser groups (or genera) 
of mental and nervous disease to the given concrete case, we 
shall not go far wrong therapeutically in any case of so- 
called Shell-shock. For Shell-shock, the pathological event, 
becomes a humble variety or species of disease whose thera- 
peutic indications are in larger part those of higher and com- 
paratively well-recognized genera of disease, e.g., hysteria, 
neurasthenia, psychasthenia. 

A shock is not a smash, a crush, a breach. A shock liter- 
ally shakes. The shaken thing stays, for a time at least. 
Shaken up or down, the victim of shock is not at first thought 



EPICRISIS 883 

of as done for. The spirit of the language is against tke 
thought of shock as destruction or even as permanent irri- 
tation. Shock ought to be a " functional " rather than an 
" organic *' thing, as medicine bandies these terms about. 
Shell-shock or Surgical Shock, it is all one to the logic of shock, 
which is thought of as a physical or chemical disturbance of 
mechanisms and arrangements that are, or ought to be re- 
adjustable. The one character which the late Professor Royce 
told me (in conversation) he could find in the term " func- 
tional " was the idea " reversible." Shock is or ought to be, 
as a pathological event, reversible. 

If this thought is in the backs of our minds as we think of 
Shell-shock, it can readily be seen why the " organic," that is, 
non-reversible diseases, do not take kindly to the term Shell- 
shock. Shell-shock, the pathological event, prefers to be an 
item in the pathology of function. Can we further specify? 
The pathology of function, neuropsychically taken, considers 
such great groups as the psychoneuroses ; (so far as we know) 
the cy clothymias ; some of the symptomatic psychoses; 
a portion of the alcohol and drug group; some of the epilep- 
sies; perhaps the dementia praecox group; not to mention 
various unresolved psychopathias. The psychoneuroses are 
the group most innocent of every " organic " taint: the 
machinery is assumed to be most normal in them and pre- 
sumably the effects of disorder most reversible. 

Shall we not therefore accept the psychoneuroses as the 
group in which to place those pathological happenings called 
Shell-shock? It will do no harm to make this choice if we 
do it humbly in the spirit of acknowledgment that we know 
next to nothing about the psychoneuroses. The psychoneu- 
roses should fall on their knees to Shell-shock rather than 
that Shell-shock make obeisance to the psychoneuroses. For 
what is a psychoneurosis? It is a functional disease of the 
nervous system in which the mind plays an important part — 
it is also probably much else. But the " much else " is as 
likely to be found in Shell-shock as anywhere else during these 
particular years. 

Thus, rehearsing in a broad way the case arrangement of 
Section B, we find, first, autopsied cases and cases with lum- 



884 epicrisis 

bar puncture data; then cases with prominent admixture of 
organic phenomena; a few cases to illustrate the victims' own 
impressions of their disease; the long toe to top, or " cepha- 
lad" series (crural monoplegias and paraplegias, campto- 
cormias, astasia- abasias, brachial monoplegias, brachial para- 
plegias, deafmutism, blindness); the series to illustrate the 
idea of reflex or physiopathic disorders; the series of delayed 
Shell-shock phenomena; the series to show the picking out 
by Shell-shock of ante-bellum weak spots and tendencies in 
the organism; cases touching the hereditary question; pecu- 
liar and unique cases; examples of Shell-shock equivalents; 
and cases of a psychopathic rather than local hystero-trau- 
matic trend. 

90. At the outset of Section B (Shell-shock: Nature and 
Causes), we face the question of the possibly organic nature 
of Shell-shock. It is safe to say that the vast majority of 
cases of Shell-shock do not die of Shell-shock, and the col- 
lection of material from true Shell-shock cases that are killed 
by accident or intercurrent disease has proved a matter of 
great difficulty under military conditions. Of course, it is 
possible to answer the question a priori, by agreeing that 
any case with structural lesion of whatever sort, is by the 
same token not a case of Shell-shock. 

91. Apparently the most informatory case yet presented is 
that of Mott (Case 197). In this case, death came in 24 
hours, and the immediate cause of death was doubtless a 
small hemorrhage of the spinal bulb. There was a congestion 
of veins in the bulb, as well as a congestion of the pia mater 
over all other parts of the brain. Nor was the bulbar hemor- 
rhage unique, for there were a number of superficial punctate 
hemorrhages. In short, the brain was not even grossly 
normal, such as one might desire in a case of true Shell-shock 
as conceived by a priori workers. Yet, according to Mott, 
there are microscopic changes of an intimate nature that lie 
nearer to the microscopic possibilities in true Shell-shock. 
For example, in the bulb itself there was a distinct and photo- 
graphable change of nerve cells : the vago-accessorius nucleus 
had cells in a state of chromatolysis. The internal alterations 
of these cells, with dissolution of chromatic material, may 






EPICRISIS 885 

possibly indeed have been the direct cause of death or ran 
indicator of its direct cause. Here again, to accord full 
justice to Mott's contention, we are dealing perhaps more 
with a phenomenon of the cause of death than with a Shell- 
shock phenomenon. According to Mott, the Shell-shock 
symptoms themselves are due to capillary anemia and to 
nerve cell changes such as he found in various regions. These 
nerve cell lesions were of the nature of chromatolysis and 
identical with those of the vago-accessorius nucleus. In this 
connection, one thinks of the ideas of Crile concerning ex- 
haustion and its effect upon certain nerve cells and other 
cells, and indeed the whole conception runs back to the early 
years of discussion of the meaning of chromatin deposits in 
nerve cells, and to the work on fatigue of such cells. It may 
well be that Mott's suggestion is sound, and that changes of 
the order of chromatolysis are what subtend some, if not most, 
of the phenomena of Shell-shock. On account of the myriad 
interconnections of neurones and the remote effects upon 
normal neurones of disturbances of a microchemical or micro- 
physical nature in a few neurones, it would not do to throw 
out of court forthwith such a contention as that of Mott by 
triumphantly pointing to the miracle cures of certain Shell- 
shock phenomena; for it will not necessarily be the chro- 
matolytic (or otherwise microchemically or physically altered) 
cells that will be directly responsible for the symptoms in 
question. Cells whose activity is but temporarily in abey- 
ance (perhaps by phenomena akin to diaschisis) might be 
reached from an unusual source in the process of " miracle 
cure," whereupon the newly opened paths of energy might 
conceivably remain open. Nevertheless, it cannot be denied 
that there are considerable stretches of speculation in the 
thread of this hypothesis. 

92. Particularly important is the question, how frequently 
such hemorrhages as those found by Mott in Case 197 occur. 
Cases are given in the text which show such hemorrhages. 

Rather often quoted in this relation is Case 201, a case of 
Sencert, in which a shell exploded one metre away from a 
soldier and injured him so that he died that night through 
the bursting of the pleura of both lungs within a thoracic 



886 epicrisis 

cage which was quite intact. This sort of finding reminds one 
of cases in which the inner partitions of houses are burst by 
explosion when the outer walls remain intact. In particular, 
one thinks of the physical changes within an aneroid barom- 
eter, which have been shown to come about when something 
is exploded near by. If such an event may happen as the 
bursting of the lungs within an otherwise intact body, so 
also is there evidence that a similar event occurs in the ner- 
vous system. Clinical evidence of this is obtained in the 
hemorrhage and pleocytosis of spinal fluid obtained early in 
the clinical examination of certain cases. In fact, in Case 
205 (one of Souques), there is a pleocytosis of the fluid as 
late as a month after shell-shock. When there is no pleocyto- 
sis or hemorrhage, there may be a hypertension of the fluid, 
— a finding sometimes attributed to Dejerine (see, for ex- 
ample, Case 207, of Leriche). It might be inquired whether 
the fall sustained by the patient as a result of the shell ex- 
plosion could not be responsible for the hemorrhage, and this 
may indeed be the fact in certain instances. Babinski has 
offered in Case 209, an instance in which hematomyelia 
(with later partial recovery) was produced in a subject who 
was lying prone in the performance of machine-gun duty (the 
phenomena in this case were well described by the victim him- 
self, a veterinary student who was six months a captive in 
Germany). Doubtless, it would not be difficult to produce 
a complete series of cases with and without trauma to the 
tissues investing the nervous system, with definite clinical 
or autopsy evidence of organic lesions of the nervous system, 
whether by mechanical impact, by the concussion (windage) 
of the air, or even by the effects of muscular contractions. 

93. A case of Chavigny's (Case 198), in which there was an 
extremely careful autopsy, showed a strongly blood-stained 
cerebrospinal fluid; in fact, there was an intradural hemor- 
rhage, though of minor degree and possibly not the cause of 
death ; and throughout the brain substance there were slight 
hemorrhagic points. But there was no sign whatever of frac- 
ture of the cranial vault or base. Another case of similar 
meningeal hemorrhage but sharply localized, was Case 199, an 
instance of minor explosion in which neither skin nor muscles, 






EPICRISIS 887 

bone or viscera showed any lesion; and the death, which 
occurred in seven days, seemed hardly explicable on the basis 
of hemorrhage itself. In fact, this case would require the 
sort of microscopic examination performed by Mott in Case 
197 for a proof of the cause of death, which was thought by 
the reporters themselves (Roussy and Boisseau) to be within 
the field of histology. 

94. Case 200 seems to bring proof that there may be areas 
of gross softening within the spinal cord produced by the 
concussion of the cord from shell-burst, although there had 
been no fracture of the spine itself and no penetration of 
splinters of shell or of bone into the spinal canal or the sub- 
stance of the cord itself. The argument here is that the 
tissues that lie between the agent of violence and the interior 
of the spinal cord are affected en bloc by the impact, the re- 
sultant gross or molar lesions being several millimetres or 
centimetres from the point reached by the impinging body or 
force. How complicated such a situation might be, we may 
recall from a case previously studied, namely, Case 103 
(Lhermitte) , wherein a missile struck the left side of the skull 
and produced lesions beneath its point of impact, but at the 
same time apparently caused a contre-coup effect upon the 
opposite hemisphere. That particular case did not come to 
autopsy, but Lhermitte's explanation of its queer association 
of aphasia with ipsilateral hemiplegia seems sound enough. 
In fine, what with the mechanical trauma to which many 
victims of shell explosion are subject, what with the findings 
in sundry autopsies, and what with the determination of 
hemorrhage in the spinal fluid early after the shock, it might 
be conceived that the majority of cases of Shell-shock are 
actually cases of mechanical injury to the brain or spinal 
cord in which hemorrhage or laceration and overriding of 
neuronic tissues would be found. Nor would such a hy- 
pothesis be prima facie absurd with the evidence afforded by 
certain cases of Shell-shock having an admixture of reflex 
phenomena and other symptoms proved by the older neurol- 
ogists to be beyond peradventure organic. (Compare, for 
example, such a case as that of Case 210, with herpes zoster 
and segmentary symptoms.) It should be remembered, how- 



888 epicrisis 

ever, that Mott in the case cited above (Case 197) sharply 
distinguishes between the hemorrhages (especially the bulbar 
hemorrhage which caused death) and the nerve cell chro- 
matolysis which he regarded as possibly at the basis of 
Shell-shock symptoms. It is decidedly doubtful whether 
the hypothesis of microscopic or larger hemorrhages, or of 
local areas of destruction of neurones will suffice for the 
explanation of true Shell-shock. This is not to say that in 
the diagnosis of true Shell-shock (that is, roughly speaking, 
the psychoneurosis) , we shall not need to concede and con- 
sider in every case the possibility of traumatic focal brain 
disease. This will always need to be faithfully excluded in 
all cases unless the initial set-up of symptoms is so suggestive 
of immediately curable psychoneurosis that without further 
ado miracle-therapy is undertaken and executed. But in 
virtually all the slower cases, an exclusion of organic brain 
and cord disease is undertaken. Admixtures of organic and 
focal phenomena are quite in the order of everyday occur- 
rence. 

95. Especially good instances of this co-existence of func- 
tional and organic symptoms are found in ear cases; and 
it may be suspected that when, after the war, all these data 
can be suitably gathered and compared, it will be from the 
field of otology that some of the most fruitful hypotheses will 
be developed. In the cases of Shell-shock deafness, mechani- 
cal peripheral factors are admixed with central factors in 
phenomena admitting in some ways more exact diagnosis 
than in other fields. We may await the correlation of these 
data by some worker, equally skilled in otology and neurology, 
with the profoundest interest. Analogous results may be 
hoped from a correlation of neurological and ophthalmo- 
logical conceptions. 

96. Suffice it to say that the differentiation of organic and 
functional phenomena has long been possible on the basis of 
what we know concerning various reflexes (e.g., the Babin- 
ski reflex and its congeners) ; and the net result of this work 
is that the majority of Shell-shock cases, — that is, cases in 
which the physical factor shell-shock has entered, — are prob- 
ably not cases in which a coarse organic disease could be 



EPICRISIS 889 

proved to exist, or assumed with any color of likelihood to 
exist. Even limiting ourselves to cases in which the physical 
factor shell-shock or some sort of impact with or without 
an external wound occurred, we shall find cases enough of a 
truly functional nature, as indicated by their reflexes, to 
render it quite impossible to assert that they are in the classi- 
cal sense " organic " cases. Putting these cases with the 
physical shell-shock factors together with the other large 
series of cases in which precisely similar symptoms occur 
without the presence of the physical shell-shock factor, we 
shall find ourselves convinced that classical Shell-shock phe- 
nomena are by and large what is called functional. We shall 
arrive at the hypothesis that they are cases of hysteria or 
other form of psychoneurosis, entitled to the diagnosis of 
traumatic hysteria (or hysterotraumatism, in the sense of 
Charcot), or not, according to whether the physical factor 
shell-shock was in evidence. What now underlies the 
concept functiona , as we use it in Charcot's sense of 
hysterotraumatism, or in th e more modern phrase trau- 
matic hyster a? Do we perhaps mean some microchemical 
or microphysical change of a reversible nature, similar to 
that described by Mott, e.g., in Case 197? It is not possi- 
ble to answer this question at this time. 

97. But if we give up the hypothesis of organic disease of 
the nervous system (that is, the hypothesis of coarse lesions, 
small or large, conceived to be the direct effect of mechanical 
impact), can we incriminate any other factor? Chemical 
factors from the gas of bursting she' Is may be thought of; 
yet in abundant cases there is no evidence that these have been 
in play. They and a variety of other special causes may be 
found working in a few instances but have nothing to do with 
the moot question. 

98. Upon giving up the organic hypothesis, the modern 
functionalist is very apt to run directly into the embrace of 
hysteria. If a thing is not physical, it must be psychical in 
its genesis, so runs the argument. What, after all, is a neu- 
rosis? We mean ordinarily by neurosis, something functional 
rather than structural. We often mean something psychical 
rather than peripheral. Accordingly, as we have seen, many 



890 EPICRISIS 

writers rush to the hypothesis that Shell-shock effects, except 
in a few unusual instances of organic disease, are functional; 
and not only are they functional but psychic, and main- 
tained by some of the so-called " mechanisms " which abound 
in modern speculative writing. 

99. Case 253, a case of Tinel, may serve to illustrate this 
point. Tinel' s patient was not subject to shell-shock at all, 
but was wounded in the arm. Three weeks later, he was able 
to flex his forearm only by means of the supinator longus. 
It was found that the biceps was soft and flaccid, though the 
electrical reactions of the biceps were normal. Now, since 
flexion of the forearm is normally produced by a synergic con- 
traction of the biceps and supinator longus, the situation in 
Tinel's case was striking in that the functions of the biceps 
and supinator longus had been separated out by a process 
which could not be hysterica . The hypothesis is that in 
hysteria it has always been found impossible to split the 
synergic action of these two muscles. What has happened? 
In Tinel's picturesque phrase, the biceps muscle has been 
stupefied by a process which involved no destruction of a 
nerve trunk or any important nerve elements. This process 
of stupefaction passed away with a few weeks* massage and 
rhythmic faradism. But what is this process of stupefaction, 
as Tinel calls it? No definite answer can be given. But is 
not the process analogous to what may happen in a variety of 
cases of shell explosion in which, for one reason or another, 
sundry neurones are, as it were, stupefied, stunned, anes- 
thetized, or thrown out of gear by some internal physico- 
chemical readjustment of unknown nature? Perhaps that 
readjustment, though in Tinel's case it probably took place 
within the tissues of the arm itself, is analogous to the chro- 
matolytic process in nerve-cell bodies suspected by Mott to 
be at the bottom of certain Shell-shock symptoms as in Case 
197. 

100. Are there, then, phenomena of peripheral nerve shock 
analogous to the phenomena of spinal cord and brain shock 
which we find in so many cases? But if so, it is clearly 
unnecessary, and indeed injurious for us to conceive that 
cases proved not to be organic must necessarily be hysterical. 



EPICRISIS 89I 

Several authors have called a halt upon this undue extension 
of the concept of hysteria to include all the non-organic 
phenomena. Take, for example, the case of the Victoria 
Cross winner (Case 529), reported by Eder, in which a con- 
tracture was shown by hypnosis to be a representation of the 
patient's clutch upon his bayonet (he had been at Gallipoli 
and was wounded in fourteen places during a bayonet fight 
with Turks). It would not be possible — in fact, it would 
seem almost impolite — to refuse to entertain the hypothesis 
of a kind of symbolism in the bayonet-clutch contracture of 
Eder's case; but it would, on the contrary, be far from 
exact to consider all cases of contracture to be even probably 
or possibly symbolic in the manner of the bayonet-clutch. 
There are, many workers feel, many functional phenomena 
that are non-hysterical, and as it were infra-hysterical in the 
sense that the " mechanisms" (to use that over- worked term) 
are in neurones below the level of complexity required by 
hysteria. This theoretical possibility (that the functional 
should be divided into the psychical and the infrapsychical) 
has been given a new status by the work of Babinski and his 
associates. That work seems to show that the older doctrines 
of Charcot concerning the existence of " reflex " disorders, 
are perfectly sound. 

101. Babinski has been able to bring into the light of 
observation the morbid operation of certain of these reflex 
arcs. Even in cases where in the waking life the central 
nervous system is able to overpower the reflex arcs in question 
and permit the limb or limbs to work reasonably well and 
smoothly, the process of chloroform anesthesia will quickly 
bring out an odd and unsuspected interior situation. The 
chloroform suspends the operation of numerous neurones, 
including those that have to do with the downflow of cerebral 
inhibitions, those si ent streams of impulse that serve to 
keep the knee-jerks, for example, in leash. Now at a time 
when all the other muscles of the body are relaxed, the with- 
drawal of the cerebral inhibitions by chloroform anesthesia 
may cause a phenomenon to appear in certain reflex arcs that 
argues an excess of activity; thus in the leg, for example, an 
ankle-clonus, or a patella-clonus, or a degree of contracture, 



892 EPICRISIS 

may be brought about early in chloroform anesthesia, though 
there had been little or no suspicion of such a tendency in the 
waking life. The cerebral inhibitions in the waking life 
have been enough to dampen the ardor of the reflex arc in 
question. It must be remarked that these cases of reflex, or, 
as Babinski termed them, physiopathic disorders, as a rule 
occur in cases locally wounded. It is the locally wounded 
limb that develops functional excess of contained reflex arcs. 
Does this occur by a process of neuritis, or by some other 
unknown process? Whatever the answer to this question, 
Babinski and his associates appear to have shown the exist- 
ence of a group of physiopathic or reflex disorders ; disorders 
below the level of the psyche and below the theatre of oper- 
ations of hysteria. 

102. Practically speaking, also, it is important not to 
consider every functional situation hysterical, since the non- 
hysterical functional changes may be extremely obstinate to 
treatment. Both physician and patient suffer if the patient 
is treated along psychotherapeutic lines for hysterical symp- 
toms, some of which turn out on investigation to be functional 
enough but non-psychic. The peculiar configuration of 
symptoms shown in cases with the physical shell-shock or its 
equivalent, is perhaps dependent upon what neurones are 
locally affected. If there has been good evidence of near-by 
explosion or of wound, it will be especially important to 
learn just what parts of the nervous system and just what 
synergic neurones and other structures were affected. 
Whether the process within these neurones be one analogous 
to the dissolution of chromatin, or whether the process is 
more like one of narcosis, or narcosis and stupefaction, or 
whether the process is more like that of a stun, or like the 
plight of the nerves in a foot for a long time " asleep," it may 
be impossible to say; but it is entirely unnecessary to soar 
directly to the higher mental process, unnecessary in short, 
to assume a hysterical dissociation when the dissociation may 
be far lower down in the nervous system. 



epicrisis 893 

The Treatment of Shell-shock Neuroses 

103. We have pictured the practical situation in which the 
neuroses of the war find themselves — a situation bristling 
with diagnostic difficulties. The great proposition deducible 
therefrom is, 

The diagnostic problem in Shell-shock is the diagnostic 
problem of neuropsychiatry at large, 

The neuroses of war have this in common with the neuroses 
of peace — that they need to be distinguished from all other 
nervous and mental diseases. One cannot be a specialist in 
Shell-shock unless one is a neuropsychiatric specialist; even 
the neuropsychiatrist has much to learn from the internist, 
the orthopedist, the neurosurgeon, as well as from the psychol- 
ogist. 

But however wide the diagnostic field for Shell-shock, the 
therapeutic field is wider still. For the neuropsychiatric re- 
construct! onist has to face the peculiarities of the military 
status of his ward, the difficulties of demobilization into 
civilian life (a canal system with very precise technic for the 
opening and closing of locks), the choice and timing of the 
proper measures of bedside occupation, of occupation therapy 
in a broader sense, of prevocational and vocational training 
— the whole comp icated by the character changes that may 
have set in to bowl over all one's preconceptions. The nub 
of the matter, after the era of the maniere forte, the brusque 
psychotherapy, the rough jarring of the man back into ap- 
proximate normality is, perhaps, this potentiality of subtle 
character changes defying possibly anybody's analysis, but 
stimulating us all to our best endeavor, whether we are physi- 
cians, psychologists, occupation-workers, social workers, or 
nurses. Now that all sorts of reconstruction programs are 
in the air, each claiming its share, or more than its share, of 
attention, let us not forget that no one can stake out in any 
small plot the measures of refitting, readjustment, readapt- 
ation, rehabilitation — all these terms with slightly differing 
denotation have been used — especially when we take into 
account that not only must the patient be refitted to his en- 



L 



894 epicrisis 

tourage, but also not seldom the entourage to its returned 
Shell-shocker. 

104. It is proper to place these general considerations first 
because the slow, patient, prosaic measures of reeducation 
are apt to be forgotten in our enthusiasm for the lightning- 
like cures of the hypnotic, the psychoelectric, the pseudo- 
operative, and other psychotherapeutic forms. Psychother- 
apy in all its forms has come into its own in Shell-shock. 
Miracles or their equivalents are daily wrought by men who 
are not prophets. Lourdes and Christian Science have their 
unassuming rivals. Let us remember, however, that even 
Lourdes and Christian Science never solved 100% of the 
problems placed before them, even though the votaries have 
the best will in the world to be cured. If the will itself is 
disordered, what can be done save investigate? And the 
mauvaise volonte is by no means absent from some of our 
prospective patients; witness one man, a Frenchman, who 
so resented being cured by tor pillage, i.e., by the electric 
brush, that he carried his case against Clovis Vincent, who 
cured him of his hysteria, clear to the Academy! And, even 
after we have cured our cases by these modern miracles, let 
us not be too proud of ourselves! One soldier sent back to 
Australia, hysterically mute for months, got his voice back 
after killing a snake — a peculiar instance of occupation- 
therapy, not enumerated in courses on reconstruction. And 
remember the man who jumped the wall and got drunk, 
breaking back into the hospital to show his doctor how his 
refractory voice had at last come back. Thus there are cures 
and cures (even a newspaper cure of mutism by a moving 
picture vision of the antics of Charlie Chaplin), and spon- 
taneous non-medical cures as well as medical ones, and slow 
cures due to vis medicatrix, as well as to shrewd reeducation 
measures. 

105. I shall not attempt to cover systematically the topic 
of Shell-shock therapy in this epicrisis. The reader must go 
through the treated cases, especially in Section D but passim 
elsewhere, if he is to obtain a proper conception of all the 
methods so far employed — and at the end he cannot know 
the ultimate outcome of the cases. Patrons of the miracle 



EPICRISIS 895 

cures and the manihre forte are having their day : on the whole, 
the law of sudden onset, sudden ending has much to say for 
itself in the hysterical (pithiatic) group. Forebodings of 
relapse in these torpedoed cases may indeed have some foun- 
dation: but figures are yet lacking, and relapses may be as 
expectantly predicted in the slow-onset, slow-cure group. 
The decision must be post-bellum. Nor must the fact that 
a few absolutely normal subjects have succumbed de novo 
to Shell-shock blind us to the fact that, statistically speaking, 
most cases are ab ovo psychopaths in whom relapses, recur- 
rences, or new instances of neurosis may be confidently ex- 
pected. For these ab ovo psychopaths, what can suffice but 

(a) removal of the disease by the vis medicatrix naturae; or 

(b) reeducation, intellectual or (c) moral (as the case may be) ; 
or else (d) some plan of environmental shielding from new 
occasions of disease? 

106. I shall content myself with a brief survey (insisting 
that the details be read of at least the leading cases in 
each treatment subgroup) of the cases offered in Section D 
(Shell-shock: Treatment and Results), consisting of 117 cases 
(Cases 473-589). The cases are in general arranged with 
the spontaneous and quasi-natural cures at the outset, — 
a series of 11 cases (Cases 473-483). The remainder of the 
section deals with cures under medical conditions, although 
many cases naturally show an interplay of non-medical factors 
in the cure or persistence of one or more symptoms. 

A few cases illustrative of the physical value of hydro- 
therapy, mechanical therapy, and drugs are given in a short 
series (Cases 484-489). A treatment of hysterical contrac- 
tures by induced fatigue is dealt with in Cases 489-493 ; and 
the occasional value of surgery is shown by Case 494. 

The simpler methods of persuasion and explanation follow 
in a series of 19 cases (Cases 495-513). 

Pseudo-operations and suggestive operative manipulation 
of avail in the treatment of certain local hysterical phenomena 
are considered in a series of eight cases (Cases 514-521). The 
comparatively long hypnotic series follows: 27 cases (Cases 
522-548). The above-mentioned cures by pseudo-operation 
and by hypnosis may be classified with those that follow, i.e., 



896 EPICRISIS 

mainly rapid cures by psychoelectric methods and by sug- 
gestion on emergence from anesthesia (Cases 549-574), as 
modern miracles These cases of modern miracle are followed 
by a briefer set of reeducative cases (Cases 575-589). 

Throughout the treatment section are scattered instances 
in which, not a cure, but merely a modification or even a 
persistence of symptoms was the outcome. It is useful to 
bear in mind, while reading cases in the etiological and diag- 
nostic sections, these main divisions of treatment into what 
might be called (1) spontaneous, (2) rapid (or " miraculous ") 
and (3) slow or reeducative. 

107. It is beyond the scope of this book to deal systemati- 
cally with the hospital and administrative side of these ques- 
tions. Especially the zone question is of practical importance, 
that is, the question of arrangements at the front, on evacu- 
ation lines, and in the interior. Roussy and Lhermitte have 
particularly discussed these matters. 

After thirty months' experience in the psychiatric centers 
of two armies, Damaye suggested an organization of psychi- 
atric centers in two parts, — First, a service draining 
patients from the firing line, rapidly give them first care and 
evacuate them, in charge of special attendants, to: Second, a 
psychiatric or neurological center in the communication zone 
(Stapes) without danger of bombardment and at a distance 
from the guns. The more serious cases will then be evacuated, 
thirdly, into the interior from these centers along communi- 
cation lines. But most will have gotten well at the front. 

108. By orthopedists and mechanotherapeutists too much 
stress may indeed be laid on non-psychiatric measures, as 
Duprat hints. Yet perhaps neuropsychiatrists may need 
as much coaching in the opposite direction. One must 
remember the non-psychopathic fraction of these Shell-shock 
disorders and their need of diathermy (Babinski). Duprat 
says that the centers for physiotherapy cannot effectively do 
the work of all Shell-shock therapy, as the physiotherapists 
have their aims fixed on nerves and muscles rather than the 
mind. Each case requiring psychotherapy ought to be 
studied in an experimental psychological laboratory from a 
number of points of view such as mechano-motor capacity, 



EPICRISIS 897 

L 



PSYCHOELECTRIC AND REEDUCATIVE TREATMENT 

Phase I. PERSUASIVE TALK IN CONSULTING ROOM 
Phase II. ISOLATION, REST IN BED, MILK DIET (a few days) 

Phase III. FARADIZATION 

Phase IV. REEDUCATION (Physiotherapy and Psychotherapy) 

Phase V. AFTER-CARE 

Curing a psychoneuropath means victory in a moral battle! 

After Roussy and Lhermitte 



Chart 19 



898 EPICRISIS 



TREATMENT FOR INVETERATE HYSTERICS 

Phase I. " TORPILLAGE " AND INTENSIVE REEDUCA- 
TION 

Phase II. FIXATION OF PROGRESS BY EXERCISES 

Phase III. PROLONGED SPECIAL TRAINING 

After Clovis Vincent 



Chart 20 



EPICRISIS 899 

the sensibility, emotional and intellectual sides, memory,; 
impulses and the like. Testing apparatus should be available 
together with dynamometers, sphygmometers, chronoscopes, 
ergographs, pneumographs, cardiographs and recording ap- 
paratus. 

Specialists for consultation should be available, including 
ophthalmologists, otologists, laryngologists and electrical 
specialists. The tests over, the patient should be examined 
as it were, in a free state and his habits and character noted. 
Hypnosis may be tried but it should not be prolonged. 
Psychic contagion is to be avoided especially in the case of 
subjects with epileptoid crises. 

It would be well to establish for the cases regarded as sus- 
ceptible to psychotherapy, reeducation centers like those for 
the re-adaptation of the tuberculous. The improved tuber- 
culous are sent to health centers under the Ministry of the 
Interior for three months at the maximum and emerge much 
better able to support the exigencies of life. According to 
Duprat, there ought to be psychotherapy centers which should 
not in any sense recall asylums for the insane. Set in the 
country but not far from the city, managed by the psycho- 
logical physicians and " medecins psychologues, plus educateurs 
que medecins" The personnel should consist of students 
going into psychiatry and of teachers whose pedagogical 
practice ought to enable them to second the efforts of the 
psychiatrists. In this way we might avoid the perpetuation 
of some of the psychopathies of war. 

109. Possibly " putting forward the best foot " may 
yield a wrong impression of the proportion of what I have 
termed " miracle cures." Other devices of a slower nature 
are mentioned throughout the book. Perhaps much de- 
pends on the temperament of the psychotherapeutist, as e.g., 
Laignel-Lavastine has remarked about the method of psycho- 
therapy by means of conversation : that one might easily re- 
main in a honeymoon state in military psychotherapy. When 
hundreds and thousands of functional nervous cases pass 
through one's hands it is necessary to remember that behind 
the conversation there stands the imposing finger of material 
force. 



900 EPICRISIS 

Compare the work of Clovis Vincent, Yealland, Kaufmann. 

no. On the other hand, Rows points out that shock is a 
term that does not explain at all adequately the great variety 
of mental illnesses occurring in the soldiers at the front. The 
term is popularly used for cases which recover quickly, but 
in the majority of cases there is a residuum after the shock has 
disappeared. Accordingly Rows' work has dealt chiefly with 
underlying causes, conditions, and factors. Here we may 
consider 

(a) The war strain before breakdown ; 

(b) Special causes of shock, such as death of comrades 

near by, near-by shell explosions and blowing up 
of trenches; 

(c) Fatigue and exhaustion with lowered capacity of 

resistance. 
The men themselves find that they have 

(d) undergone a change of character, having become 

irascible, unable to sustain interest and attention; 
solitary and morose, and less capable of self-con- 
trol. Anxiety, worry and a state of morbid ex- 
pectancy set in. Everyday trifles are exaggerated. 
But below these cases are still deeper ones, such 
as 

(e) revival of horrible memories and terrifying dreams 

of war scenes, together with memories of incidents 

of past life. 

(Rows attributes to Dejerine the idea that the 

cause of all cases of hysteria and neurasthenia 

must be sought in antecedent emotion.) 
Emotion compels attention, and to such a degree in some 
cases that the memories and attendant fears and anxieties 
cannot be expelled. Hallucinations and delusions may then 
develop. The patient is largely incapable of reasoning about 
his status; he lacks " insight into the nature and mode of 
origin of his mental illness. This insight can be provided by 
explaining to him in plain language the mechanism of simple 
mental processes, by enabling him to understand that every 
incident is accompanied by its own special emotional state, 
and that this emotional state can be re-awakened by the re- 






EPICRISIS 901 

vival of the incident in memory." The patient and the 
physican now " begin to realize that they have some ground 
in common .... The mystery of the illness will be swept 
away and the physician will be able to . . . show him how 
he can educate himself to regain that which was lost." 
" The patient can be induced to face the trouble." " The 
excessive emotional tone will thus be stripped away and the 
patient will thus become able to appreciate the real value of 
the incident." " The reeducation must vary with each 
case in order to overcome the difficulties connected with the 
specific cause which has been discovered." 

Rows' work has been done at the Red Cross Hospital at 
Maghull, and several of the Maghull cases have been reported 
in Elliot Smith and T. H. Pear's book on Shell-shock. A 
somewhat similar point of view has been maintained by 
Wm. Brown, who has suggested the neat term autognosis for 
psychoanalysis. W. A. Turner speaks of the Maghull point 
of view as one of modified psychoanalysis. 

in. Or again a species of combination of the maniere forte 
and the maniere douce (operations, shall we say with William 
James, of the " tough-minded " and the " tenderminded " 
respectively?) may be used as in the formula 

SYMPATHY + FIRMNESS (Mott). 

112. More special devices, suggesting faintly the methods 
of animal training, may be used, as described in the following 
account of a new isolation and psychotherapeutic service 
established in May, 191 5, at the Salpetriere for soldiers with 
functional nervous diseases. The basic idea has long been 
held by Dejerine, — the avoidance of heterosuggestion by 
other patients, imitation, 11 effects of visits from members of 
the family. The functional additions that come from near-by 
organic patients are among the disadvantages of the ordinary 
treatment. The isolation service of the neurological center is 
composed of 34 beds, arranged in two halls, with three extra 
rooms. Each bed is isolated. The regime in one of the rooms 
is more rigorous than in the other, and it is an advance for a 
patient to be moved from the first to the second room. The 
patient on wakening has no right to leave his box or com- 



902 EPICRISIS 

municate with his neighbors. He leaves only to be treated 
by hydrotherapy or electrotherapy. He takes his meals in 
isolation, receives no calls, and has no leave to go out. The 
physician sees the patient twice a day and carries on psycho- 
therapy and motor reeducation, as well as special treatments. 

Women nurses care for the patients. A system of control 
and of progressive rewards has been installed, being a sort of 
metric evaluation of the process of cure. As the cure pro- 
ceeds the patient's lot is progressively mitigated, or if he gets 
worse the regime is clamped down. Suppose a man a vic- 
tim of paralysis of leg — the height to which he can lift his 
leg is measured in centimeters daily as well as the time during 
which he can hold the eg in air; or, the progress of an ankle, 
or of the forearm or the arm in a case of arm contracture, 
is measured. The grade obtained by our scholar in psycho- 
therapy is inscribed upon a slate. Finally, walks, concerts, 
visits and eventually permission to go out into the town are 
granted. 

113. Can Shell-shock neuroses be prevented, other than 
by stopping or modifying the war or by weeding out Shell- 
shock candidates as they volunteer or are drafted? Morton 
Prince offers points of some suggestive value. The very 
various proportions of neurosis observed in different units 
and arms of the service suggest that various degrees of pre- 
paredness may have played a part. Bernheim says sug- 
gestion is an idea accepted. Aside from a possible increase 
of simulation, much might depend on what idea administered 
really got accepted! Morton Prince's plan is that the pre- 
vention must be based upon the education of the mind. This 
therapeutic education should be based, however, on a pre- 
liminary systematic study by a board of specialists in the 
psychoneu roses of (a) the mental attitude of minds generally 
toward shell fire, and (b) clinical varieties of this " shock " 
neurosis as it occurs in trench warfare, (c) its frequency and 
disabling incidence, and (d) the state of mind previous to the 
trauma of those suffering from it. 

On the basis of the findings of such a study, first, the regi- 
mental surgeon through lectures and clinical demonstrations 
would be instructed systematically in the symptoms and 



EPICRISIS 903 

pathology of the disease and the methods of psychotherapy, 
for its prevention. 

Second, soldiers, including officers, could then, in units of 
say 100, in turn be instructed in the nature of the disease 
through lectures by regimental surgeons. Shell-shock, they 
should be told, is a form of hysteria caused by mental factors. 
The work of the instruction should be done in France in the 
atmosphere of the war, wherein would be formed an attitude 
of healthy mental preparedness instead of an attitude of fear 
and mystery. Has mental hygiene this great scope? Is 
morale merely education? 

114. What after all, is Morale? We hope to learn a little 
about it from this war for use hereafter, when we can say 
with the Florentine 

e quindi uscimmo a riveder le stelle 

And thence we issued out again to see the stars 

Inferno, Canto xxxiv, 139. 



BIBLIOGRAPHY Q05 



BIBLIOGRAPHY 

These references were collected in the main by Sergeant Norman Fenton 
both before and after his entering the army, in connection with preparations 
for the work of one of the Neuropsychiatric Training Schools (that at Boston), 
established by the Division of Neurology and Psychiatry of the Surgeon-Gen- 
eral's Office, U. S. Army. The work, through the year 1917, at least, is not a 
mere vernis de bibliographe, but is based on a first-hand search through journals 
available in the Boston Medical Library and the New York Academy of Medi- 
cine (to whose officers thanks are due for very special privileges accorded). 
After Sergeant Fenton's departure for service in the war neurosis hospital, 117, 
American E. F., France, the work was finished by the writer in considerable 
haste by skimming the current indexes and gathering the more prominent titles 
for 1918 (some for 1919). The titles, be it noted, go beyond the scope of the 
case-material in the body of the book and cover also a variety of reconstructional, 
reeducational, clinical-neurological, neurosurgical, and other topics bearing in- 
directly on neuropsychiatry. These auxiliary subjects are by no means com- 
pletely covered, but it was thought the titles might help other inquirers. Under 
the war conditions numerous errors have no doubt crept into the references, 
which errors we hope will not, by reason of the short space of time covered by 
the bibliography, prove particularly misleading. The auxiliary topics can be 
referred to in the Index under page-numbers after the word "Bib." 

E. E. S. 

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v. 23, p. 46. 
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v. ii, p. 178. 
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Ackerley, R. Treatment by physical methods of mental disabilities induced by 

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pp. 501-505. 
Addinsell, A. W. Head injuries in war. Brit. Med. Jour., 1916, ii, 99. 
Adler, H. M. The broader psychiatry and the war. Mental Hyg., Concord, 

N. H., 191 7, v. 1, pp. 364-370. 
Adrian, E. D. and Yealland, L. R. The treatment of some common war neuroses. 

Lancet, Lond., 191 7, i, 667. 
Adrian and Yealland. The treatment of some common war neuroses. Lancet, 

Lond., 1917, i, pp. 867-872. 
After care of nerve injuries. Rev. of War Surg. & Med., 1918, i, no. 3, 49. 
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chiques d'origine commotionnelle pendant la guerre. Presse Med., Par., 

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Aime, H. et Perrin, E. Considerations sur un cas d'epilepsie partielle guerie 

apres extraction du projectile intra-cerebral. Progres Med., Par. 1916, 

v. 3, pp. 187-189. 



906 BIBLIOGRAPHY 

Aitkin, D. M. Orthopaedic methods in military surgery. Lancet, Lond., 1917, 

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INDEX 



INDEX 



Abderhalden test, 219. 

Abdominothoracic tetanus, Case 403. 

Aboulia, 719. 

Abrahams, 639, 640, 769, Case 236. 

Accommodation paresis, 612. 

Acrocontracture, Cases 235, 428, 486, 
489, 529 (bayonet clutch), 530. 

Acroparalysis, Cases 250, 428. 

Acroparesthesia, 845, Case 132. 

Acoumeter, 809. 

Addison's disease, 239. 

Adiadochokinesis, 301. 

Adrenalin, 229, 239, 689. 

Adrian and YeaUand, 674, 702, 797, 
Cases 563, 564. 

Ageusia, 375. 

Agoraphobia, 260, 763. 

Agraphia, Cases 220. 

Aime, 672, 689. 

Albumin in spinal fluid, 280. 

Albuminuria, question of hysterical, 535. 

Alcoholism (see Pharmacopsychoses, dip- 
somania), 58, 1 13-130, 459, 589, 668, 
768, 800, 874, Cases 86-97, Bib., 907, 
910, 912, 964. 

Alcoholism, experimental, 118. 

Alexia, 161. 

Alquier, 196. 

Amaurosis (see Ophthalmology). 

Amblyopia, 374, 609-610. Bib., 959. 

Amentia, 360. 

Amnesia, 303, 392, 435, 441, 444, 453, 
462, 467, 477, 487, 488, 492, 499, 634 
(recurrent), 635, 676, 734, 739, 757, 828. 
Bib., 932, 955, 958, 968. 

Amnesia, in malaria, Case 129. Bib., 

923- 
Amyotrophy, 719, 761. 
Analgesia, 252, 253, 483, 567. 
Anaphylaxis, 114, 329, 414, 464. 
Anemia, capillary, 265. 
Aneroid, 275. 



Anesthesia, 253, 262, 277, 292, 320, 452, 

483, 498, 538, 544, 568, 575, 577, 685, 

744, 771, 783, 800, 824, 827, 872. 

Bib., 918, 961. 
Anesthesia, corneal, in normal persons, 

610. 
Anesthesia en lunettes, 610. 
Anesthesia, reeducation of, 568. 
Anesthesia, sexual parts, 531, 533. 
Ankle-jerk, 585. Bib., 906, 916. 
Ankylosis, Bib., 925. 
Anonymous, Case 481. 
Anorexia, Bib., 975. 
Anosmia, 301, 580. 
Antagonist muscles, 353, 355, 545. 
Antagonist muscles in contraction, 350. 
Antalgic reaction, 525. 
Anterior horn cell shock, 526. 
Antebellum experiences repeated in 

shell-shock hysteria, 876, Cases 286- 

301, 397, 532, 537, 576. 
Antityphoid inoculation, 842, Cases 65, 

180, 303. 
Anuria, 535. 
Anxiety neurosis, no, 260, 457. Bib., 910, 

924, 925, 927, 963. 
Aphasia, 1 59-161, 874, Case 103, Bib., 

910, 928, 929, 950, 961, 981. 
Aphasia, hysterical, non-existent, 454, 

766. 
Aphonia, 370, 725, 727, 816. Bib., 931, 

932, 940, 953, 957, 959, 963, 975, 978, 

980. 
Apoplexy, Bib., 936. 
Apraxia, Bib., 928, 936. 
Aprosexia, 487, 632, 637. 
Argyll-Robertson sign inverted (Sollier), 

612, 
Arinstein, 716, 746. Cases 212, 249, 551, 

554, 555, 588. 
Arnoux, 270. 
Armstrong- Jones, 526. 



INDEX 



Arrangement of cases (see Shell-shock, 
general arrangement of cases). 

Arteriosclerosis, 225, 866. Bib., 919. 

Arthritics, 231. 

Arthritis, 325. 

Association-experiment, Bib., 927. 

Association of hysterical and other symp- 
toms (see passim), 522, 523, especially 

530-S34. 

Association of hysteric, reflex, and or- 
ganic conditions, 605. 

Astasia-abasia, 282, 312, 362, Cases 246, 
247, 348, 402, 512, 533, 569, 576. 
Bib., 934, 973. 

Asymmetry of reflexes, chloroform, 594. 

Athanassio-Benisty, 540, 556. 

Athetosis, 876, Case 113. 

" Atmosphere of cure," 728. 

Atrocities, 860, Cases 94, 95. 

Atrophy, " reflex," 545. 

Aura, 98, 626. 

Autobiographical statements of soldiers, 
Cases 121, 209, 216, 217, 226, 227, 341, 
344, 361, 364, 463, 527, 528, 575. 

Autocritique, 63. 

Autofixity, 369. 

Autognosis, 702, 859, 901. 

Autokratow, 9, 469. 

Automatism, 431, 734. 

Autopsies, Cases 110, 118, 133, 197, 198, 
199, 200, 201. 

Auto-suggestion, frontispiece, 95, 98, 109, 
153, 395, 498, 543, 577, 674, 738, 748. 

Aviation (see also Otology), 275, 489, 
823. Bib., 907, 930, 938, 945, 959, 
960, 964, 970, 973 

Babinski, 157, 395, 401, 454, 456, 469, 
481, 491, 498, 535, 543, 544, 554, 563, 
566, 568, 569, 576, 578, 603, 604, 605, 
643, 647, 671, 723, 746, 748, 788, 819, 
833, 848, 856, 857, 871, 874, 877, 878, 
891, 896, Cases 871, 877, 878, 891, 896. 

Babinski reflex, 280. 

Babinski-Weil test, 621. 

Babinski and Froment, 389, 390, 585, 
607, 608, 695, 696, 717, 719, 742, 787, 
Cases 274, 275, 276, 422-426. 

Babonneix and Celos, Case 145. 

Babonneix and David, Cases 16, 17, 30. 

" Bait " for hysteria, 544. 



Baldwin, 374. 

Ballard, 675, 689, 736, 840, Cases 82-84. 

Ballet, 465, 554, 643, Cases 267, 396, 

407. 
Ballet and de Fursac, 404, 472, 675. 
Barany, 624. Bib., 907, 909. 
Barat, Case 75. 

Batten, Cases 113, 222, 227, 589. 
Battle hypnosis, 638. 
Beaton, 9, Case 5. 
Bechterew, 342. 
Beck, Case 439. 
"Bends," 275. 
Benisty, 331. 

Bennati, 414, Cases 186, 221, 320, 336. 
Benon, 633. 

"Bent-back" (see Camptocormia). 
BSrard, 118, 696. 
Bergonie, 790. 
Bernheim, 95, 740, 902. 
"Big belly" (see Pregnancy, hysterical). 
Bilateral symptoms, 362. 
Binswanger, Cases 179, 217, 220, 229, 233, 

239, 309, 327, 368, 483, 505, 549, 575, 

576, 577, 579, 587. 
Biological principles and neuroses, Bib. 

915- 
Birdlike movements, 487, 632, 637. 
Birnbaum, 222. 
Bispham, 644. 
Bladder, 276, 284, 294. 
Blassig, Case 264. 

Blepharospasm, Case 211. Bib. 931. 
Blepharospasm, 372, 374. 
Blin, Case 131. 
Blindness, Cases 29, 208-272, 296, 297, 

433, 517, 521, 537, 538. Bib., 915, 921, 

928, 935, 943, 952, 958, 974, 976. 
Blindness, cortical, Case 105. 
Block (see Inhibition). 
Blood, buffer salts, 640. 
Blood pressure high, 497. Bib. 232. 
Blood pressure low, 225, 228, 231, 239, 

260, 690, 851. Bib. 232. 
Blum, 661. 
Bolshevist, 249. 
Bonhoeffer, 31, 82, 8$, 222, 700, Cases 54, 

55, 57, 65, 58, 70, 71, 76, 147, 155, 158, 

340. 
Bonnet's sign, 452. 



INDEX 



Boschi, 704, 716. 

Boucherot, 36, Cases 6, 18, 86, 149, 163. 

Bouquet, Case 419. 

Bourgeois and Sourdille, 620, 623, 809. 

Brachial plexus palsy, 353, 566, 611. 

Brachial symptoms (see Monoplegia). 

Brain abscess, Case 110. 

"Brain fag," 104. 

Brain injury, 67, 265, 270. Bib. 915. 

Brain tumor. Bib. 919 (third ventricle). 

Brasch, 41, 689. 

Bravery, psychopathic, 859, Case 36. 

Briand, Case 1, 40, 43, 99, 100, 101, 

102. 
Briand and Haury, Cases 98, 467. 
Briand and Kalt, Case 461. 
Briand and Philippe, 683, Case 578. 
Broca, 160-161. 
Bronchopneumonia, 845. 
Brown, 412, 470, 901, Cases 496. 
Brown-Sequard, 89, 528, 555, 843. 
Bruce, 716, 724, 769, Cases 521, 553. 
Bulbar syndrome, Bib. 910. 
Burial, 334, 349, 373, 393, 396, 405, 419, 

435, 457, 499, 512, 573, 682, 696, 698, 

768, 779, 796, 814, 819. 
Bury, 228. 
Buscaino and Coppola, 205, Cases 34, 188, 

189, 190, 370. 
Butenko, 222. 
Buzzard, 668 (chart), 791, Cases 380, 381, 

513. 

Caisson disease, 275. 

Campbell, A. W., 669. 

Campbell, H., 373, 704. 

Camptocormia, 525, 529, Cases 242-245, 

322, 385, 401, 572, 584. Bib. 938, 950, 

95i, 956, 965, 972. 
Canities, Cases 211, 212, 540. Bib. 943, 

97i, 974- 
Cargill, Case 418. 
Carlill, Case 130. 
Carlill, Fildes, Baker, Case 2. 
Cassirer, Case 398. 
Catalepsy, local, 544, 551, 552. Bib. 916 

(post mortem), 942. 
Catatonia, 485. Bib. 928. 
Catiemophrenosis, 479. 
Cauda equina, 533, 540. 



Causes (see Shell-shock, nature and 

causes). 
Cellulitis, 764. 
Celluloid obturators, 813. 
Central gyrus lesions, 160. 
Cephalad arrangement of Shell-shock 

cases, 852. 
Cephalea, 490. 

Cerebellar symptoms, Cases 375, 398. 
Cerebellum, 268, 296, 300. 
Cerebrospinal fluid (see Spinal fluid). 
Cerumen, 813. 
Cestex, 366. 

Chaplin, Charlie, 672, 894. 
Character (see also Psychology). Bib. 

921. 
Charcot, 348, 454, 531, 544, 545, 569, 572, 

618, 719, especially 744 and 833, 848, 

867, 891. 
Charon and Halberstadt, Case 318. 
Charpentier, 608, 696. 
Chartier, Case 257. 
Chavigny, 115, 223, 275, 460, 487, 568, 

637, 656, 680, 723, 738, 740, 886, Cases 

198, 400, 446. 
Chemical warfare, 321, 574, 799, 889, 

Cases 215, 216, 232, 284, 314, 318, 360, 

367, 452, 586. Bib. 956, 962, 969, 980. 
Children (delinquent and the War). Bib. 

923, 943- 

Chloroform (Babinski's experiments), 380, 

388, 545, 554, especially 592~597, 608. 

Chorea, 421, Cases 14, 224, 300. Bib. 

924, 933- 

Chromatolysis of nerve-cells, 265, 884, 

885. 
Cintrage (see Camptocormia). 
Civilians, psychiatry of, Bib. 915, 924, 

952, 953, 965, 981, 982. 
Clarke, Cases 67, 394. 
Clarke, Michell, 701. 
Claude, 693, 979, Cases 560, 561, 573. 
Claude, Dide, and Lejonne, 509, Case 331. 
Claude and Lhermitte, 275, Cases 120, 

200, 214, 375. 
Claude, Lhermitte, Vigouroux, Case 159. 
Claustrophobia, Case 182. Bib. 964. 
Clavus hystericus, 349. 
Claw foot, 698. 
Clunet, 456. 



INDEX 



Colchicum, 239. 

Colin and Lautier, 260, Cases 32, 195. 

Colin, Lautier, Magnac, 46. 

Collie, Cases 458, 472. 

Commotio cerebri (see also Brain), 134, 

260, 366, 490, 524, 699, 888. 
Commotio spinalis, 335, 528-534. 
Compensation (see also Simulation), 14, 

28, 482, 666, 837, Cases 3, 7, 8, 22. Bib. 

910, 911, 912. 
Concussion deafness, 364. 
Conditioned reflex, 445, 467, 495, 530, 613, 

622. 
Confusion, 483, 484, 487, 492, 509, 637. 

Bib. 916, 925, 948, 954, 963. 
Consiglio, 36, Cases 63, 150, 180, 191, 367. 
Constriction edema (see also (Edema), 

569- 

Contracture, 282, 318, 525, 529, 545, 569, 
Cases 489-493 (Treatment by induced 
fatigue) and passim. Bib. 921, 926, 
933, 939, 944, 947, 956, 962, 963, 97*, 
972. 

Contrecoup, 873, 887, Case 103. 

Conversion-hysteria, 405, 823. 

Convulsions, 706, 759, 762, 820 (see 
Hysteria, Epilepsy). Bib. 941. 

Convulsions after inoculation, Cases 63, 
65. 

Corpse-contacts, 262, 375, 467, 476, 491, 
716 (no redeeming feature). 

Cortical blindness, Case 105. 

Cottet, Case 132. 

Coughing, 425. 

Courtois-Suffit and Giroux, 164. 

Crabtree, 759. 

Craig, 644, 716. 

Crampusneurose, 409, 588. Bib. 968. 

Cranial nerves, 378. 

Crile, 269. 

Criminality (see also Medico-legal, Simu- 
lation, etc.). Bib. 920, 921. 

Crises (see Emotional crises), 548. 

Crouzon, 373, 851, Cases 177, 433. 

Crutch-paralysis, 324, 605, 833. 

Cyclothymoses (Manic-Depressive 

group), 865-867, Cases 163-169. 

D.A.H. (see Soldiers' heart). 
Damaye, 153, 896. 



Dawson, Case 552. 

Deaf-mutism, 362, 405, 767, 815, Cases 
497-499, 514, 515, 517, 552, 557, 558, 
580, 585, 588. Bib. 911, 914, 937. 

Deafmutism, cure, 672, 681, 721, 734, 775, 
776, 781. Bib. 925, 946, 948, 950, 960, 

965. 
Deafness, 813, 888, Cases 259-267, 514, 

515, 522. (See also Otology), Bib. 913, 

915, 916, 917, 924, 927, 932, 933, 937, 

942, 945, 954, 962, 974, 979. 
Death, delusion, 405. 
DeBrun, Case 129. 
Decubitus, 285, 527, 533. 
DeFursac, Case 302. 
Dejerine, 528, 538, 648, 740, 819, 886, 900, 

901, Cases 288, 289, 412. 
Dejerine and Gascuel, Case 143. 
De la Motte, Cases 152, 234. 
Delherm, Cases 431, 432. 
Deliria (see also Oniric), 488. Bib. 919, 

924, 925, 929, 942, 971.^ 
Delirium, oniric (see Oniric delirium). 
Delusions, influenced by war, 214, 702,863. 
DeMassary and Du Sonich, Case 14. 
Dementia praecox (see Schizophrenoses), 

861, Cases 147-162. Bib. 935, 939, 

957, 958. 
Denechau and Matrais, 479. 
Dentistry (see teeth). 
Depressions (see also Cyclothymoses), 

714. 
Dercum's disease, 846, Case 141. Bib. 936. 
Dermatology, 331, 358, 361, 362, 535 

(see also Hypertrichosis). Bib. 914, 

921, 922. 
Desertion, Cases 1, 12, 45, 52, 56, 58, 88, 

90, 92, 149, 150. Bib. 923, 924. 
Determination of symptoms to parts of 

body, 459, 359, 360, 362. 
Diabetes mellitus, 846, Case 140. 
Diagnosis, delimitation, 834-847. 
Diagnosis per exclusionem in ordine, 847, 

871. < 
Diagnosis, Shell-shock, differentiation, 

871-880. Bib. 923. 
Diagnosis: Shell-shock, 2, 3, Cases 371- 

422 and passim. Bib. 942. 
Diathermia, 166, 607, 896. 
Dichroism, spinal fluid, 283. 



INDEX 



d 



Dide, 456. 

Dietotherapy, 476, 674, 675, 701. 

Dieulafoy, 373, 609. 

Diphtheria, 845, Cases 127, 128. Bib. 

93i, 953, 962. 
Diplegia, facial, Bib. 909, 958. 
Diplopia, monocular, 427, 613, 827. 
Dipsomania, Bib. 917. 
Disciplinary (see Medicolegal). 
Disgust (see also Corpse-contacts), 262, 

375, 467, 476, 491, 519, 855. 
Dissociation of personality, Case 369. 
Dissociation of sensations, 570. 
"Doll's head" anesthesia, 744. 
Donath, Cases 20, 306, 362. 
Dubois, 716, 740, 819. 
Dreams, hunger and thirst, 475. 
Dreams, smell, 476. 
Dreams (see also Oniric delirium), 470, 

477, 503, 582, 713, 716, 728, 732, 756. 

Bib. 947, 955- 
Dromomania (see also Fugue), Case 191. 
Duco and Blum, Case 22. 
Dumas, 637. 

Dumesnil, Cases 167, 168, 185. 
Dumolard, Rebierre, Quellien, Case 110. 
Dupouy, Cases 161, 300, 377. 
Duprat, 896, 899, Cases 51, 346, 442, 443. 
Dupre, 437, 459. 
Dupres and Rist, Case 292. 
Duret and Michel, 273. 
Duvernay, 554, Case 486. 
Dynamopathic, 856, 871. 
Dysarthria, 159, 356. 
Dysbasia (see passim), 560, Cases 248, 

278; especially 397-400; 537,547,560, 

561. Bib. 941. 
Dysentery, 586, 705. 
Dysentery, psychosis, Case 122. 
Dyskinesia, 633. 
Dysmnesia, 637. 

Ear, injuries of (see also Otology), Bib. 

929, 932, 937, 940, 943, 948, 949, 955, 

957, 962, 981. 
" Earthquake hysterias," 881. 
Ecmnesia, 438. 
Eczema, 429. 
Edema, hysterical, 535, 569, 646, 663. 

Bib. 909, 942, 943. 



Eder, 702, 740, 750, 891, Cases 178, 296, 
359, 529, 544. 

Edinger, 414. 

"Effectives," military, 56, 161. 

Elective exaggeration of reflexes, 380 (see 

Physiopathic). 
Electrotherapy (see also Treatment, psy- 

choelectric), Bib. 916. 
Elliot, Cases 210, 237. 
Embolism (see Fat, Gas). 
Emotion, 266, 348, 413, 539, 559, 582, 

589, 635, 679, 701, 706, 713, 735, (B 

group, emotional, Myers), 808, 900. 

Bib. 909, 919, 920, 923, 926, 939, 941, 

944, 947, 948, 954, 955, 958, 963, 964, 

965, 968, 976, 978. 
Emotion and epilepsy, 97, 413, Cases 85, 

302. 
Emotional crises, 453, 455. 
Emotional factors absent, Case 239. 
Emotional shock, Cases 334-339, 343. 

Bib. 928. 
Encephalitis (alcoholic?), 459. 
Encephalopsychoses (focal brain group of 

mental diseases), 490, Cases 103-121. 
Enterospasm, Bib. 928. 
Enuresis, 70, 252, Cases 51, 61. Bib. 

964, 967. 
Epilepsy, see Epileptoses. 
Epilepsy, "affect," 97. 
Epilepsy, Brown-Sequard's, Case 69. 

Bib. 947. 
Epilepsy, hysterical, treatment of, 628. 

Bib. 938. 
Epilepsy and inoculation (see Convul- 
sions). 
Epilepsy, Jacksonian, 158, Cases 66, 105, 

441 (hysterical), 547 (same). Bib. 916, 

922, 925, 938, 944, 965. 
Epilepsy, larvata, 73, Case 81. 
Epilepsy, late, 93. 
Epilepsy, pleural, 187. 
Epilepsy, "reactive," 70, 102, Cases 57, 

70, 76. Bib. 933. 
Epileptic equivalents, 112, 488, 490. 
Epileptoses (Epileptic Group), 675, 699, 

839-843, Cases 53-85. Bib. 905, 910, 

911, 937, 938, 939, 945, 947, 956, 961, 

968, 972, 973, 975, 977. 
Equilibrium- tests (see Otology). 



8 



INDEX 



Erb's palsy, 598. 

Ereutophobia, 432. 

Erichsen, 544. 

Erythromelalgia, Bib. 916. 

Eschars, 285. 

Eschbach and Lacaze, Case 108. 

Espionage, 126, 201. 

Etats commotionnels , 832. 

Etats emotionnels, 832. 

Etats seconds, 72, 108, 530. 

Etiology (see Shell-shock, Nature and 

causes). 
Ether versus chloroform, 769. 
''Excommunication" by inhibition, 369, 

403. 

Exhaustion, 102, 228, 469, 482, 689, 

699. 
Experimental work, 294. 
Explosive diathesis, 700. 
Explosives, high, 115, 266, 294, 295. 
Exposure, 519, Case 239. 
Eye (see also Ophthalmology), Bib. 932, 

934, 94o, 94i, 962, 964. 
Eye, functional cases, Cases 432-437. 
Facial paralysis, 530. 
Facial spasm, Case 306. 
Facies, deaf mutism, 815. 
Faradism (see Treatment, Shell-shock 

neuroses, Psychoelectric) . 
Farrar, Case 8. 
Fat embolism, 24. 
Fatigue, 225, 231, 375, 448, 469, 498, 502, 

557, 639, 689, 708, 855, 900. Bib. 907, 

924, 929, 931, 937, 941, 943, 948, 964, 

975- 
Fatigue, induced (see Treatment). 
Fauntleroy, 275. 

Fear, 64, 223, 258, 338, 375, 404, 425, 
440, 441, 451, 466, 519, 675, 855. Bib. 
907, 958. 

Fearnsides, 12. 

Feeblemindedness, 857, Cases 35-52. 

Feebleminded, of use in army, 48, Cases 
35, 37, 41. 

Feiling, 750, 775, Case 369. 

Ferrand, 390, Case 567. 

Finger-prints, Bib. 916. 

First name extraordinary, Case 48. 

Fluorescein test, 372. 



Focal brain lesions with mental disease, 

Cases 103-121 (see also under En- 

cephalopsychoses) . 
Foix, 159. 
Formulae of Shell-shock, 4, 5, chart 2 

(page 6), chart 3 (page 7). 
Forster, 348, 349. 
Forsyth, 702, Cases 286, 297 
Foucault, 405, 561. 
Fractures, Bib. 906. 
Fraser, 364. 
Freud, 39, 702, 716. 
Friedmann, 843, Case 77. 
Friedreich's disease, 551. 
Froment (see also Babinski and Fro- 

ment), Case 203. 
Fugue a deux, 235. 
Fugue, alcoholic, 841, Case 88. 
Fugue, catatonic, 202, Case 149. 
Fugue, emotional, Cases 43, 52, 75. 
Fugue, epileptic, 72, 841, Cases 58, 61, 

62, 75. Bib. 977. 
Fugue, hysterical, 850, Cases 171, 173, 

368, 444. 
Fugue, melancholic, Case 164. 
Fugue, obsessive, Case 445. 
Fugue and oniric delirium, 471, 569. 

Bib. 914, 917, 948. 
Furloughs, 685. Bib. 919. 

Gaillard, Case 137. 

Gait disorder (see Astasia-abasia, Dys- 

basia). 
Gallavardin, 641. 
Galvanism, (see Treatment, Shell-shock, 

Neurosis, Psychoelectric). 
Ganser symptom, 212, 213. 
Garel, 723, Case 581. 
Gas embolism, 270. 
Gassing (see Chemical warfare). 
Gastroenterology (see Stomach). 
Gastropaths, 400. 
Gaucher and Klein, Case 313. 
Gault's cochleopalpebral reflex, 624. 
Gaupp, Cases 226, 259, 317, 334, 353, 

359, 449, 469. 
Gayet, 26. 
General paresis, 9, 18, 223, Cases 2, 6, 9, 

12, 15. Bib. 924, 946, 947, 949, 953, 

958. 



INDEX 



t 



Genito-urinary, 260. 

Genito-urinary disorder, see Urology. 

Geriopsychoses (senile-senescent group), 

200, 225, 262. 
Gerver, 31, Cases 157, 166, 255, 257, 258, 

347, 350, 351, 352. 
Giles, Case 466, 474. 
Gilles de la Tourette, 18. 
Ginestous, Case 268. 
Gleboff, 644, 663. 
Glueck, 667. 
Glycosuria, Bib. 919. 
Goldstein, 723, 728. 
Gonorrhoea, 41, 260, 261. 
Gordon sign, 157. 
Gosset, 624. 
Gougerot and Charpentier, Cases 428, 

429, 430. 
Gradenigo, Cases 465, 557. 
Grandclaude, 486. 
Grant, Dundas, 683, 738, 809. 
Grasset, 405, 501, 522, 523, 638, 724. 
Gray hair (see Canities). 
Green, Case 169. 
Greenlees, Case 269. 
Grenier de Cardenal, Legrand, Benoit, 

Case 118. 
Griinbaum, Case 532. 
Guillain, 281, 421, 746, Case 372. 
Guillain and Barre, Cases 31, 112, 382, 

384, 402. 
Gunshot head wounds, see especially 

under Encephalopsychoses. 

Hahn, 222. 

Hair (see Canities, Hypertrichosis). 
Hallucinations. Bib. 944, 948. 
Hallucinations, auditory, 367, 371, 431, 

484, 493- Bib. 913. 
Hallucinations, experimental, 460. 
Hallucinations, Lilliputian, Case 106. 
Hallucinations, pain and temperature, 

452. 
Hallucinations, smell, 478. 
Hallucinations, tetanus, 164. 
Hallucinations, visual, 485, Cases 159. 
Harris, 404, Case 565. 
Harwood, Case 436. 
Haury, Case 46, 154. 
Head, Henry, 641. 



Headache, 255, 258, 524, 525, 526. 

Head injury (see also cases under Ence- 
phalopsychoses wounds), Bib. 905, 906, 
907, 912, 913. 

Head sensations, 321, 490. 

Heart, neurosis, 35, 400, 477, 689, 764 
(see also Soldiers' heart, Precordial sen- 
sations). Bib. 909, 914, 927, 929, 930, 

93i, 934, 936, 937, 945, 95<>, 95 1, 959, 

968, 969, 974, 975, 976, 977. 
Heat stroke, 447. 
Hecht, 838. 

Heilbronner's sign, 157. 
Heitz, Case 134. 
Heliotherapy, Bib. 954. 
Helmet, Bib. 916. 
Hemeralopia (see night-blindness). 
Hematology (see Blood). 
Hematomyelia, 277, 284, 286, 555, 570. 
Hemeralopia, Bib. 907, 914, 927, 929. 
Hemiageusia, 476. 
Hemianosmia, 476. 
Hemianesthesia, 876, Cases 114, 218, 255, 

376, 380, 554. Bib. 958. 
Hemianopsia, 428, 616. Bib. 930, 931, 

953, 974, 977- 
Hemicontracture, 529. 
Hemichorea, 411. 
Hemiplegia, 282, 293, 302, 874, especially, 

877, Cases 255, 256, 281, 291, 292, 372, 

408, 412, 551, 554. Bib. 926, 931, 934, 

936, 943, 945, 946, 949, 953, 958, 959, 

960, 964, 966, 971, 977. 
Hemiplegia, organic, minor signs of, 157. 

Bib. 925, 933, 950. 
Hemorrhages of brain, 265, 270. Bib. 

955- 
Hemorrhage, bladder, Case 202. 
Hemorrhages, meningeal, 270, 271, 372. 

Bib. 933. 
Hemorrhages, naso-pharyngeal. Bib. 

921. 
Hemorrhages of skin, 358, 362. 
Hemorrhage, spinal, 888, Cases 202 ; 372. 
Henderson, Case 183. 
Heredity, 289, 401, 418, 419, 668, 812. 
Heredity and acquired soil absent in 

Shell-shock, 348, 349, 401, 418, 419. 
Herpes, 288. 
Hesnard, 212. 



IO 



INDEX 



Heterosuggestion — frontispiece, 109, 153, 

395, 674, 676, 767, 777, 794, 901. 
Hewat, Cases 53, 299, 571. 
Hippus, 87. 
Hirschfeld, Case 484. 
Histology, 265, 271, 272. 
Hollande and Marchand, Case 141. 
Homosexuality, 257. 
"Honeymoon" psychotherapy, 899. 
Hoover's sign, 157. 

Horse (in the unconscious), Case 359. 
Hospital organization, 896. Bib. 907. 
Hoven, Cases 156, 183, 333. 
Howland, 748. 
Hunger dreams, 475. 
Hunter, John, 608. 
Hurst, 91, 736, Cases 4, 15, 24, 25, 64, 72, 

78, 80, 238, 378, 399, 501, 514, 527, 

538, 543, 548. 
Hydrophobia, Case 118. 
Hydrotherapy (see Treatment), Bib. 905, 

906, 911, 929, 936. 
Hyperalbuminosis (see Spinal fluid), 

Cases 371, 373. 
Hyperalgesia, 288, 299, 579, 583. Bib. 

95i- 
Hyperacusis, 367. 
Hyperboulia, 859. 
Hyperesthesia, 267, 700, Cases 221, 223, 

262, 383. Bib. 960. 
Hyperreflexia, hysterical, 535. 
Hypersensitive phase (see Anaphylaxis). 
Hypertension, spinal fluid, 282, 283. 
Hyperthyroidism, 361, 639, 640, 760, 844, 

846, 866, Cases 142-145, 315, 326, 497. 

Bib. 939, 965. 
Hypertonus (see passim), 543, 545. 
Hypertrichosis, 89, 567. 
Hypnotism in blind, 377. 
Hypnotism, 96, 282, 509, 532, 554, 702, 

729 (blind), 731 (deaf), 743 (not in 

French army), Cases 142, 174, 361, 

369. Bib. 934, 951, 953, 955, 957, 964, 

967. 
Hypnotism, spontaneous, 504-508. 
Hypochondria, 231, 260. 
Hypophrenoses (Feeble-mindednesses) , 

Cases 35-52, 236. Bib. 920, 935, 940, 

941, 942, 957, 962, 977. 
Hypotoniaj 350, 592. 



Hysteria, 69, 152, 165, 211, 213, 253, 
Cases 67, 68, 123, 128, 137. Bib. 917, 
924, 930, 932, 940, 942, 943, 944, 945, 
952, 956, 957, 965, 973, 974, 975, 978, 
979, 982. 

Hysterical symptoms in sleep, 554. 

Hysterical and organic symptoms, Cases 
116, 117, 134, 214, 219, 230, 231, 399, 
495. Bib. 924, 928, 933, 981. 

Hystero-emotive factors, 456, 509. 

Hystero-organic association, 605, 799. 

Hystero-reflex association, 605. 

Hystero- traumatism, 531, 544, 545, 560, 
568, 571, 799. Bib. 918, 933. 

Imaginary symptoms, 833. 

Imboden, 288, 693, 793. 

Incontinence of urine (see Urology), 
Cases 384, 401, 500, 577. 

Indemnity-neurosis, 348. 

Industrial medicine, 854, 873. 

Infection (see also Somatopsychoses), 
488, 509, 875. 

Inferno, passim. 

Inhibition, 355, 356, 369, 653, 891. 

Inoculation and convulsions (see Con- 
vulsions). 

Insomnia, 299. Bib. 945. 

Insular sclerosis (see Multiple Sclerosis). 

Intermediolateral tract shock, 526. 

Iron cross and psychopathy, 863, Case 
158. 

Iron cross and psychotherapy, Case 479. 

Instinct (see Emotion, Psychology, etc.), 
Bib. 921, 934, 978. 

Insubordination, 77, Cases 47, 59, 60, 63, 
93. 

Isolation, see Treatment. 

Jacquet's biokinetic treatment, 646. 
James, 632, 901. 

Jeanselme and Huet, 538, Case 441. 
Jelly-fish not shocked, 858. 
Joint-disease, 539, 545, 562, 569, 608, 

744, 789- 
Jolly, Cases 176, 349. 
Joltrain, Case 245. 
Jones, 692, Case 476. 
Joubert, Case 374. 
Jousset, 609. 



INDEX 



L 



Jumping-jack, Case 555. 

Jung, 240. 

Juquelier, Case 58. 

Juquelier and Quellien, 97, Case 81. 

Kaplan, 700. 

Karplus, 348, Cases 27, 140. 

Kastan, 860, Cases 11, 12, 13, 44, 45, 47, 

49, 89, 90, 91, 92, 93, 94, 95, 96, 97, 

104, 148, 151. 
Kaufmann's Treatment (see Treatment, 

Shell-shock Neuroses, Psychoelectric), 

723, 75°, 753, 786, 791, 792, 793, 900. 

Bib. 940, 945, 962, 968. 
Khoroshko, 227. 
Kidner, 803. 
King, Edgar, 210. 
Klippel and Weil, 528. 
Knee-jerks, loss of (matutinal), Case 110. 
Kocher, 343. 
Korsakow syndrome, in malaria, Case 

130. Bib. 916, 930. 
Kyphosis, 340. 

Labilizing factors, 329. 

Labyrinth disease, 366, 623, Case 211. 
Bib. 955, 966. 

La Carotte, 660. 

Laehr, 689. 

Laignel-Lavastine, 14, 570, 796, 899. 

Laignel-Lavastine and Ballet, Cases 38, 
438. 

Laignel-Lavastine and Courbon, 560, 
Cases 29, 106, 170, 194, 314. 

Laignel-Lavastine and Fay, Case 74. 

Lannois and Chavanne, 657. 

Laryngology, 576, 683, 721, 723, 726, 727, 
766, 823 (see also Treatment, Shell- 
shock neuroses, pseudo-operations). 
Bib. 909, 912. 

Lasegue, 452, 483. 

Lattes, 257. 

Lattes and Goria, Cases 196, 266, 295, 
319, 321, 322, 323. 

Lautier, 36, Cases 42, 48, 56. 

Lebar, 569, Cases 211, 456. 

Lepine, 18, 27, 30, 72, 73, 75, 81, 82, 91, 
112, 113, 120, 126, 155, 202, 231, 260, 
458, 473, 490, 638, 860. 

Lereboullet and Mouzon, Case 105. 



Leri, 498, 696, 723, Cases 114, 228, 393. 

Leri, Froment and Mahar, Case 411. 

Leri and Roger, Cases 252, 468. 

Leriche, 886, Cases 66, 206, 207. 

Levy, 331. 

Lewandowski, 348, 674, 724. 

Lewitus, Case 471. 

Lhermitte, 157, 874, 887, Case 103. 

Liebault, 726, Cases 261, 447, 580, 585. 

"Lightning neuroses," 881. 

Lilliputian hallucinations, Case 106. 

Lipomatosis, 846, Case 141. 

Lloyd Morgan, 374. 

Localizing sense, 557. 

Localization of hysterical symptoms (see 

passim) 529, 855, 872, 873. 
Locus minoris resistentiae, Shell-shock 

hysteria, 36, 854, 876, Cases 286-301, 

409-414. 
Loewy, Cases 87, 122, 310. 
Logre, Cases 21, 62, 88, 164, 235. 
Long, Case 10. 

Lortat- Jacob and Sezary, Case 316. 
Lumbar puncture (see Spinal fluid and 

Treatment). 
Lumiere and Astier, Case 119. 
Lumsden, 645. 
Lungs, 846. 
Lust, 228. 

Lymphatics, Bib. 906. 
Lymphocytosis of spinal fluid (see Spinal 

fluid and Meningitis). 

MacCurdy, 683, Cases 193, 232, 293, 307, 

332, 355, 415, 451, 452, 586. 
MacMahon, 738, Cases 582, 583. 
MacKenzie, 641. 
Main oV accoucheur , 593. 
Mainfigee, 593. 
Main succulent, 186. 
Mairet, 401. 

Mairet and Durante, 294. 
Mairet and Pieron, 92, Cases 28, 69, 448, 

450. 
Mairet, Pieron, Bouzansky, 134, Case 

330. 
Maitland, 225. 
Maixandeau, Case 107. 
Malaria, 845, Cases 129-131. Bib. 923, 

926, 961. 



12 



INDEX 



Malingering (see Simulation, Medico- 
legal, etc.), 5i4, 554, 642, 643, 707, 717, 
Cases 453-472. Bib. 920, 927, 931, 
936, 938, 94o, 948, 950.' 955, 958, 969, 
974, 975, 976, 982. 

Mallet, 487, Cases 354, 444, 445. 

Mania, Cases 163, 165, 187, 188, 350, 351. 

Manic-depressive psychoses (Cyclothy- 
moses), Cases 163-169. 

Manic-depressive (also see Cyclothymia), 
Case 16. 

Manure forte, 189, 893, 895, 901. 

Mann, 718, 793, 797, Cases 240, 265, 356. 

Mannkopf-Thomayer test, 415. 

Marage, 809, 813. 

Marchand, Cases 127, 128. 

Marie, 14, 159, 342, 648, 796, Cases 403, 
470. 

Marie, Chatelin, Patrikios, Case 9. 

Marie-Foix sign, 157. 

Marie and Levy, Case 213. 

Marie, Meige, B6hagne, Case 401. 

Marionette movements, 350. 

Marriage, H. J., Case 260. 

Martial misfit, 415, 668. 

Martinet, 231. 

Massage, 353, 529, 566. Bib. 918, 940, 

959, 961, 97i- 

Mathieu, 796. 

Maurice, 231. 

Mauvaise volonte, 717, 812, 894, Case 
228. 

McDougall, 374. 

McDowell, Cases 495, 500. 

McWalter, 391. 

" Mechanisms," 890, 891. 

Mechanotherapy (see also Treatment), 
Bib. 914. 

Medicolegal, 509 (see also Desertion, Fu- 
gue, Epilepsy, Simulation, etc.), 837, 
838, 841, 862, 864, Cases 1, 3, 11. 
Bib. 914, 917, 920, 925, 926, 932, 935, 
938, 940, 941, 942, 943, 944, 952, 953, 
956, 960, 961, 973, 977. 

Medicolegal period in general paresis, 18. 

Meige, 331, 432, 465, 696, 746, Cases 224, 
308, 413. 

Meiopragia, 592. 

Melancholia, Cases 164, 166, 168, 169. 

Memory (see Amnesia, Hypnosis, etc.). 



Mendel-Bechterew's sign, 157. 

Mendelssohn, Cases 111, 208. 

Meniere's disease, 623. 

Meninges (see also Hemorrhage), Bib. 
912 (cysts). 

Meningitis, 875, Case 109. Bib. 927, 930, 
967. _ 

Meningitis (Meningococcus), Cases 107, 
108. Bib. 906. 

Meningitis (pneumococcus), Case 112. 

Mental disease (in war), 926, 936, 937, 
963, 966, 967, 975, 980, 981, 982. 

Mental hygiene, Bib. 955. 

Mental symptoms, Bib. 917. 

Meriel, 548. 

Merklen, Cases 125, 126. 

Meta traumatic hysteria, 329. 

Meyer, 50, 208, 222. 

Meynert, 62, 226. 

Micawber, 674. 

Micromegalopsia, Case 106. 

Micro-organic changes, 572. 

Milian, 501, 638, Cases 171, 364, 365, 366. 

Military psychiatry (see War and Psy- 
chiatry). 

Milligan and Westmacott, 365. 

Milligan, 775. 

Mills, Cases 454, 459, 517. 

Mine-explosion, 492. 

"Miracle" cures (see Treatment, Shell- 
shock, rapid versus slow, and passim, 
885). 

Mitchell, Weir, 821. 

Mobilization, neuropsychiatry of, Bib. 
908, 929. 

Molecular changes, 572. 

Monier-Vinard, 388. 

Monoplegia, 282, 317, 318, 323, 539, 591 
(diagnostic table), 595, 596, 605, 874, 
Cases (crural), 229-234, 286, 287, 385, 
386, 388, 410, 428, 534, 575, 577, Cases 
(brachial), 249-254, 281, 404, 405, 409, 
421, 426, 427, 429, 430, 563, 564, 571, 
573. Bib. 954. 

Montembault, 222. 

Moore, 641, 644. 

Morale, 9, 257, 903. 

Morchen, 228. 

Morestin, Case 516. 

Morphinism, Cases 99-102. 



INDEX 



ft 



Morselli, 222, 226, 645. 

Mott, 158, 228, 476, 643, 689, 704, 719, 
728, 775, 797, 813, 884, 885, 887, 888, 
901, Cases 85, 197, 262, 328, 341, 344, 
414, 473. 

Muck, 726. 

Multiple sclerosis, 309, 422, 530, 580, 876, 
Case 115. 

Musculospiral nerve, 540. 

Musical alexia, 775. 

Mutism, 282, 454, Cases 185, 219, 226, 
227, 283, 330, 356, 365, 447, 473, 475, 
476, 480, 516, 520, 526, 528, 531, 544, 
550, 555, 556, 559, 578, 586. Bib. 916, 
924, 927, 931, 932, 933, 946, 954, 964. 

Mutism, classification (Myers), 369. 

Mutism, treatment, 674 and passim. 
Bib. 915, 927, 976. 

Myelitis (see Spinal cord lesions). 

Myers, 355, 568, 579, 740, 750, Cases 
174, 223, 263, 272, 287, 329, 360, 361, 
395, 453, 463, 464, 523, 524, 525, 538. 

Myokymia, 361. 

Myopathy, question of Shell-shock, 574. 

Narcolepsy, 487, 843, Case 77. 

Narcosis (see Treatment, Narcosis). 

Naval Service, Bib. 910, 929, 965. 

Neiding, Case 215. 

Neisser, 838. 

Neri's sign, 452. 

Nerve concussion, 354. 

Nerve leaks, Bib. 910. 

Nerve lesions, peripheral (see also Neuri- 
tis), Bib. 905, 909, 910, 916, 918, 920, 
921, 925, 926, 928, 933, 934, 935, 936, 

937, 938, 939, 94i, 945, 947, 948, 949, 
95o, 95i, 953, 955, 956, 957, 958, 959, 
960, 963, 965, 967, 968, 970, 971, 972, 
973, 975, 976, 977 (large nerve trunks), 
923 (median), 914, 923 (electrical 
methods of diagnosis), 922. 

Nerve sutures, 916, 926. 

Nerves (and the War), 915, 953, 956. 

Nervous system, 922, 923, 925, 928, 933, 

938, 940, 944, 945, 958, 959, 962, 963, 
967, 971, 972, 973, 975, 978. 

Nervous temperament, 956. 
Neurasthenia, 231, 578, 639, 718, Cases 
143, 175, 176, 177, 179, 284, 340, 349, 



416, 420, 545. Bib. 914, 915, 916, 920, 

925, 930, 95o, 957, 964, 969, 975, 980. 
Neuritis, 89, 574, 583, 598, 843, 846, 

Cases 127, 128, 130, 131, 132, 135, 387, 

417, 418, 512, 540. Bib. 907. 
Neuropsychiatry, Bib. 915,922, 924, 926, 

947, 95i, 952, 955, 960, 963, 969, 976, 

980. 
Neurological centers, Bib. 918, 923, 941, 

956, 961, 966, 971, 972, 981. 
Neurologists in war, Bib. 914. 
Neurology (see War and neurology). 
Neuropotential, 268. 
Neurosis, definition, 831-834, 889. Bib. 

926, 938, 939, 946, 947, 952, 957- 
Neurosyphilis, Cases 1-34, 53, 110. Bib. 

916, 972. 
Neurosyphilis and exhaustion, 31. 
Neurosyphilis and trauma, 838. 
Night-blindness, Bib. 907, 911, 942, 959, 

975, 979, 980. 
Nitrophenol, Case 434. 
Nitrous oxide anesthesia, 769. 
Noise, 308. 
Nonne, 282, 348, 716, 718, 736, 748, 

Cases 248, 479, 530, 531, 533, 535, 536. 
Nose, see Rhinology. 
Nosophobia, Case 261. 
Nostalgia, 440. Bib. 927. 
Nystagmus, 432, 489, 557. Bib. 952, 

956, 975- 

Obsessions, 229, 466, 631. 

Obturators, aural, 813. 

Obtusion, 487, especially, 637. 

Occipital lesions, 159, 217. 

Officers' susceptibility to Shell-shock, 

735, 744, 857. 

Old age, 200, 225, 262. 

O'Malley, Cases 515, 518. 

Oniric delirium, 405, 437, 456, 477, 478, 
628, Cases 50, 81, 295, 314, 319, 321, 
331, 333, 444, 477, 579. 

Oniric delirium, treatment by prear- 
ranged emotional shock, 461. 

Ontological fallacy, 833. 

Ophthalmology (see Vision, etc.), Cases 
268-272, 433-438. Bib. 906, 907, 910, 
911, 916, 918, 930, 931, 938, 941, 944, 
954, 955, 97o. 



14 



INDEX 



Ophthalmoplegia, Case 19. 
Ophthalmoplegia externa, 613. 
Oppenheim, 157, 348, 361, 401, 747, 749, 
Cases 146, 256, 311, 326, 376, 379, 405, 

420, 427. 

Organic neurology (see Encephalopsy- 
choses, Trauma, and passim), 158- 
161, 489. Bib. 914. 

Organo-hysterical association, 605. Bib. 
916. 

Organopathic, 856, 871. 

Orientation-sense (see Otology). 

Ormond, 653, Case 537. 

Ormond and Hurst, 729. 

Orthopedics, 356, 692. Bib. 906, 910, 915, 
927, 93i, 939, 947, 950, 953, 957, 963, 
970. 

Otology (see Ear, Labyrinth, Vestibular, 
Deafness, Mutism, Aviation), 888, 
Cases, 259-267, 370, 414, 439, 440, 
497-499, 562, 578, 579, 588. Bib. 907, 
913, 916 (Equilibrium, Orientation), 
919, 925, 962. 

Over-reaction, 307. 

Over the top, 481, 699. 

Overwork, if. 

Pachantoni, Case 273. 

Pactet and Bonhomme, Case 52. 

Pain, see Antalgic hallucinations. 

Panic (see Psychology, Emotion, etc.), 
Bib. 922. 

Paranoia, Case 185. Bib. 960. 

Paraphernalia, 785 (see Atmosphere of 
cure) . 

Paralyses (see also Hemiplegia, Mono- 
plegia, Paraplegia, etc.), (P. Bra- 
chialis), Bib. 919, 943; (traumatic), 
923, 927, 933; (facial), 955; (func- 
tional), 977. 

Paraplegia, 282, 284, 541, 769, Cases 236- 
241, 279, 288, 374, 379, 387, 393, 394, 

421, 479, 511, 536, 555, 568, 572. Bib. 
919, 923, 926, 927, 929, 930, 935, 938, 
939, 947, 949, 95°, 952, 956, 966. 

Paratyphoid fever, psychosis, 845, Cases 

125, 126. Bib. 952. 
Paresthesia, 357, 359. 
Parinaud, 618. 
Paris, 84. 



Parkinson, Cases 138, 139. Bib. 933, 
95?. 

Parkinson's disease, 422. 

Parsons, 653, Case 270. 

Pastine, 693. 

Pathological intoxication, Cases 86. 87, 

90, 96. 
Pathological lying, Case 183, 
Paulian, 576, Case 385. 
Pearson, 373. 

Pellacani, Case 59, 60, 187. 
Pemberton, Case 271. 
Penhallow, 769. 
"Pensionitis," 666. 
Pensions (see Medicolegal), Bib. 914. 
Periorganic hysterical symptoms (see 

passim), 529-534, 544, 548 (tetanic), 

563, 569, 849, 873. 
Personality disorder (see also passim and 

Psychopathoses), 493, 512. Bib. 927. 
Persuasion, 96. Bib. 927. 
Petrol-injection, Case 98. 
Pharmacopsychoses (Alcohol, Drug, and 

Poison group), Cases 86-102. Bib. 925. 
Phillipson, 364. 
Phobia (see Psychoneuroses, Psychas- 

thenia), 627, 628. 
Phobias, 464. 

Phocas and Gutmann, 846, Case 136. 
Photophobia, 372, 511. 
Physiopathic declacifkation, Case 429. 
Physiopathic disorder, 380, 521, 543, 544, 

554, 585 (diagnostic table), Cases 274- 

281, 421-428; 591 (diagnostic table), 

878, 892. Bib. 932, 953, 954, 956, 964, 

966, 977, 978. 
Physiopathic electrodiagnostics, 608. 
Physiopathic disorder, cure, 387, 607, 671. 

Bib. 928. 
Physiotherapy, 821, 896, 897. Bib. 914, 

918, 920, 926, 929, 931, 935, 939, 948, 

95o, 95i, 957, 960, 967, 975, 978. 
Pick, Case 33. 
Pied fige, 330. 
Pitres and Marchand, 837, Cases 23, 109, 

115, 218. 
Pitres and Regis, 423. 
Pituitrin, 228, 690. 
Plantar reflex, question of absence, 537, 

538, 575- Bib. 923. 



INDEX 



«S 



Pleocytosis (see Spinal fluid). 

Pleura, hemorrhage, Case 201. 

Pleura, reflex disorder, 186, 846. 

Plicature (see Camptocormia). 

Plumbism, 584. 

Pneumonia, Case 133. 

Podiapolsky, 740, Cases 539, 540. 

Podmanizky, 693. 

Poliencephalitis, 26. 

Poliomyelitis, 574, 598. 

Polyneuritis neurasthenica (Mann), 718. 
Bib. 925, 957. 

Poliomyelitis, residuals, Case 113. 

Pollakisuria, 347 

"Poor dears!", 719. 

Popliteal nerve, 354, 540, 600. 

Post-diphtheritic symptoms, Case 127. 

Post mortem (see Autopsies). 

Post-oniric suggestion, 477, 628. 

Potain, 239. 

Pott's disease, 343. 

Precordial sensations, 477, 526. 

Predisposition, 401 (see also frontispiece). 

Prefrontal lesions, 159. 

Pregnancy, hysterical, 387, Case 348. 
Bib. 966. 

Prestige, 819. 

Prevention of Shell-shock, 3, 902. 

Prince, Morton, 902. 

Prisoners, 228, 303. Bib. 913. 

Proctor, 769, Cases 480, 556. 

Pruvost, Cases 35, 36, 37, 39, 41. 

Pseudodementia, Bib. 910. 

Pseudologia phantastica, Case 183. 

Pseudocoxalgia, 323, 341, 819. 

Pseudohallucinations, 430. 

Pseudo multiple sclerosis, 155. 

Pseudoparesis, Case 26. 

Pseudoptosis of Charcot and Parinaud, 
618. 

Pseudotabes, Case 23. 

Psoitis, 525. 

Psoriasis, Case 313. Bib. 930. 

Psychasthenia, Cases 170, 178, 194, 342, 
347. Bib. 910, 921, 929, 942, 975, 980. 

Psychiatric social work, Bib. 917, 938, 
956, 972. 

Psychiatrists in war, Bib. 914, 927, 950. 

Psychiatry in war (see War and psy- 
chiatry). 



Psychoanalysis, 361, 497, 582, 675, 677, 
702, 712-716 (rationalization), 851, 901 
(autognosis). Bib. 926, 937, 979. 

Psychoelectric treatment, 285, 313. 

Psychogenesis, 69, 83, 332, 337, 348, 351, 
497, 744, 855, 871. Bib. 919. 

Psychological laboratory, 896. 

Psychology, passim, also Bib. 907, 911, 
924, 925, 928, 931, 932, 934, 936, 937, 
938, 941, 943, 946, 947, 952, 955, 956, 
959, 960, 962, 963, 964, 968, 971, 873, 
876, 982. 

Psychoneuroses, Cases 170-182. Bib. 
926. 

Psychoneuroses of war, Charts n and 12, 
pages 522 and 523, 760, 761, 799. Bib. 
932, 940, 941, 943, 95s, 956, 959, 960, 
961, 965, 966, 972, 973, 976, 978, 981. 

Psychopathic constitution, Case 147. 

Psychopathic hospitals, 3, 680, 871. 

Psychopathic inferiority, Case 186. 

Psychopathology of War, Bib. 917, 922, 
926, 954, 971, 972. 

Psychopathoses (Psychopathias), Cases 
183-196. Bib. 935, 948, 957, 960, 962, 
969, 977, 980. 

Psychoses, 2-262, Chart 1 (page 2). Bib. 
915, 918, 922 (acute), 926 (post-shell- 
shock), 927 (Dysglandular), 927, 928, 
934, 936, 94o, (vesical) 943, 952, 
955, 957, 958, 962, 965, 968, 972, 973, 
975, 976, 978, 979, 980, 982 (see also 
Mental diseases [in war]). 

Psychoses, treatment, Bib. 918. 

Psychotherapy (see Treatment); also 
chart 16 (page 673). 

Psychotic symptoms in hysterical cases, 

327. 
Puerilism, Case 318. Bib. 912, 917, 941. 
Pulmonary phenomena, 846. 
Pupils in Shell-shock, 526. Bib. 933. 
Purser, Case 475. 

Quadriplegia, 528, 530, 551, 573. 
Quincke's disease, 646, 665. 

Rabies, 844, Case 118. 
Radial paralysis, 350, 351. 
Radicular symptoms, Case 134. 
Railway spine, 5, 348, 544, 831, 873. 



i6 



INDEX 



Raimiste, 528. 

Ranjard, 809. 

Rationalization (Rivers), Cases 506-510 
(see also Treatment: Shell-shock neu- 
roses), 237, 859. 

Ravaut, 275, 281, Cases 202, 373, 408, 
488. 

Raynaud, 569. 

Reaction-psychosis, 304. 

Reactive idealization, 468. 

Realsuggestionen, 799, 803. 

Reconstruction, 831, 859, 893 (see Treat- 
ment, Shell-shock neuroses, Mechano- 
therapy, Reeducation, etc., etc., and 
passim). Bib. 908. 

Recovery (see Shell-shock). 

Recruits, possible elimination of defective 
(see also Hypophrenoses), 835, 858, 
Cases 42, 44, 49, 91. Bib. 906. 

Rectal incontinence, 807. 

Recurrence, Cases 286-301. 

Reeducation (see Treatment, Shell-shock 
neuroses, Reeducation), also Bib. 906, 
914, 91s, 916, 918, 920, 922, 923, 925, 
926, 927, 928, 930, 931, 933, 93s, 937, 
938, 940, 942, 943, 948, 949, 950, 951, 
952, 954, 956, 957, 961, 962, 963, 964, 

969, 971, 978. 

Reeducation, respiratory, 808, 814-818. 
Reeve, 793, Cases 489, 490, 491, 492, 493. 
"Reflex" disorder (see Physiopathic) . 
Reflexes, Bib. 919, 925, 934, 939, 953, 

970, 971, 977, 978. 
Refrigeration, 424, 590. 

Regis, 62, 72, 233, 461, 478, 509, 631, 637, 
638, 680, 850. 

Relapse (see also "Reminiscence" proc- 
ess in shell-shock), 403, 404, 457, 463, 
495, 675. 

Religiosity, 256. 

"Reminiscence" process in Shell-shock 
hysteria, Cases 286-301, 314. 

Responsibility (see Desertion, Fugue, In- 
subordination, Pharmacopsychoses) ,72, 
100, 117, 171. 

Responsibility a psychogenic factor, 458. 

Retention of urine (see also Urology), 
Cases 111, 382, 383, 539 (Hypnotism). 

Retrobulbar neuritis, 609, Case 434. 

Retrocentral lesions, 160. 



Rhinology, 262, 321, 375, 476, 511, 665. 

Bib. 955. 
Riggall, Case 541. 
Rivers, 476, Cases 506-510. 
Rombergism, Shell-shock, 620. 
Romner, Case 406. 
Rontgenology (see X-Ray). 
Rosanofl-Saloff, Mme., 340. 
Roselle and Oberthur, 456. 
Rossolimo's sign, 157. 
Rothacker, Case 144. 
Rouge, Cases 153, 162. 
Roussy, 281, 696, Cases 133, 279, 387, 

460, 497, 498, 499, 502. 
Roussy and Boisseau, 275, 362, 404, 689, 

743, 797, 815, 887, Cases 199, 440. 
Roussy, Boisseau, Cornil, Case 348. 
Roussy and Lhermitte, 466, 471, 476, 

487, 509, 525, 56o, 563, 578, 637, 701, 

726, 738, 743, 787, 807, 896, Cases 230, 

235, 243, 244, 246, 247, 250, 291, 572, 

584. 
Routier, Case 409. 
Rows, 471, 478, 900, Cases 301, 335, 342, 

343. 
Russca, 295. 
Russel, 404, 650, 740, 775, 781, Cases 79, 

241, 503, 504. 

Saaler, 208. 

Salmon, 804. 

Sargent and Holmes, 158. 

Sartorius muscle, 553. 

Savage, 48, 83, 404. 

Schafer's sign, 151. 

Schizophrenia and typhoid fever, Case 
124. 

Schizophrenoses (Dementia praecox 
. group), 202, 223, 861-865, 864 (medi- 
colegal), Cases 124, 147-162. Bib. 

9*3- 
Scholz, Case 550. 
Schultz, 726. 
Schultzer, Case 570. 
Schuster, 343, 349, Cases 19, 234, 298. 
Sciatica, Cases 10, 565. 
Scotoma, 98, 374. 
Sebileau, Case 388. 
Secretory disorder, 387. 
Seguin and Rouma, 809. 



INDEX 



4? 



Self-inflicted injury, Cases 153, 187, 193. 

Bib. 917, 921, 922, 926, 961, 969. 
Sencert, 885, Case 201. 
Senility (see Geriopsychoses), 200, 225, 

262. 
Sensibility (see Dermatology, Opthal- 

mology, etc.). Bib. 923, 946, 955, 962, 

969, 978, 980. 
Serbians, 102, 225, 228. 
Sereysky, 297. 
Serology (see Syphilopsychoses, also 

under Spinal fluid). 
Sexual continence, 459. 
Sex sensations, 259. 
Shell-shock: animal experimentation, 294, 

295- 
"Shell-shock," the term, 5. 
Shell-shock and croix de guerre, 430, 675. 
Shell-shock: Diagnosis, Cases 371-472 

and passim. Bib. 915, 922, 941. 
Shell-shock: Nature and Causes, Cases 

197-370 and passim. Bib. 917, 918, 

920, 926, 927, 928, 935, 937, 942, 958, 

967, 977, 981. 
Shell-shock: Treatment and results, 

Cases 473-589 (and see special head- 
ings under Treatment, Shell-shock). 

Bib. 967. 
"Shell-shock" diseases, 880. 
Shell-shock and epilepsy (Ballard's 

Theory), Cases 82-84. 
Shell-shock and traumatic neurosis, Case 

248. 
Shell-shock equivalent, 850. 
Shell-shock, general arrangement of cases, 

852 et seq., 879-880, 883, 894 et seq. 
Shell-shock, nature in general, 847, 867, 

880-892. Bib. 926, 931, 932, 934, 946, 

950, 952, 953, 954, 955, 961, 962, 965, 

967, 968, 971, 974. 
Shell-shock: organic hypotheses, 526, 

Cases 197-222. Bib. 927. 
Shell-shock, relapse, 391. 
Shell-shock, repeated, 299. 
Shell-shock (spelled with capital letter) 

versus shell-shock (spelled lower case), 

880. 
Shell-shock, symptoms delayed, Cases 

282-285. 
Shell-shock, terminology, 831-834. 



Shell-shock, treatment in general, 893, 
adfinem. Bib. 921, 923, 924, 929, 930, 
934, 936, 937, 953, 954, 976, 978. 

"Shock" ought to be "functional," 883. 

Shufllebotham, Case 417. 

Shunhoff, 228. 

Shuttleworth, 48. 

Sicard, 525, 544, 554, 643, Case 462. 

Simulateurs de creation, de fixation, 643. 

Simulation (see malingering, medicolegal, . 
etc.), 42, 91, 260, 569, 592, 605, es- 
pecially 642-667; 661-662 (list of 
methods). Bib. 914, 916, 917, 922, 
925, 927, 928, 932, 934, 936, 939, 940, 
941, 942, 945, 946, 949, 953, 955, 956, 
958, 959, 960, 962, 963, 964, 965, 967, 
969, 970, 974, 975, 976, 977, 978. 

Simulation, Cases 33, 34, 39, 78, 79, 257. 
Bib. 907, 909, 910, 912, 917, 918, 920, 
924, 946. 

Sirene d voyelles, 908. 

Situation-delirium, 699. 

Skin-lesions (see Dermatology). 

Skin reflexes, 538, 543. 

Skull, see Head and Wounds. Bib. 916 
(Protection, etc.). 

Slang, 832. 

Sleep, deep, 70. 

Sleep, Shell-shock not produced in, 349. 

Sleep, hysterical symptoms persistent in, 
553. Bib. 971. 

Smell (see Rhinology). 

Smirnow, 740. 

Smith, E., 471, Cases 175, 284. 

Smith, E., and Pear, T. H., 672, 740, 
901. 

Smith, R. P., Case 192. 

Smyly, Cases 116, 117, 219, 283, 397, 
520, 558, 559. 

Snake killed, 678. 

Social work (see also Social Psychiatry), 
2, 859, 893. 

Soldier, Bib. 927; Mind of, in field, Bib. 
927. 

Soldiers' heart, 44, Cases 138, 139, 451, 
452. Bib. 905, 924. 

Sollier, 538, 554, 603, Cases 389, 390, 
487. 

Sollier and Char tier, 531. 

Sollier and Jousset, Case 434. 



i8 



INDEX 



Somatopsychoses ("symptomatic" of 

bodily [non-nervous] disorder), 843- 

847, Cases 118-146. 
Somatopsychoses (Symptomatic, non- 
nervous group), Cases 122-146. 
Somnambulism, 70, 499, 502, 503, 504, 

506, 508, 509. 
Soukhanoff, 120, Cases 50, 223. 
Souques, 91, 342, 345, 696, 886, Cases 

242, 386. 
Souques and Donnet, Case 371. 
Souques and Megevand, Case 401. 
Souques, Megevand, Donnet, Case 205. 
" Spa" treatment, 718. Bib. 957. 
Spasms, 409, 548, 563, 571, 577, 588. 

Bib. 951. 
Spasm, facial, Cases 222, 309. Bib. 944. 
Spasm, glossolabial, 563, Case 309. 
Spasm, head, Cases 223, 413, 588. 
Spasticity, 427. 
Speech disorder, Cases 217, 219, 369, 377, 

527 (see also Stuttering). Bib. 922, 

932, 934, 94o, 945, 947, 949, 95°, 951, 

955, 968, 969, 975, 979, 981. 
Specialists in escape, 81. 
Sphincter-disorder (see also Urology). 

Bib. 916, 933. 
Spinal cord lesions, 562, 887, Cases 111, 

133, 372; especially Cases 375-381. 

Bib. 915, 919, 920, 945, 946, 950, 965, 

978. 
Spinal fluid, 149; especially 276-283; 

344, 398, 421, 506, 521; especially 524- 

527; 53°, 535, 536, 539, 57o, 576, Bib. 

909, 951, 972. 
Spine (see under Camptocormia). 
Spondylitis, 342, 525, Bib. 921. 
Spondylotherapy, Bib. 909. 
Spontaneous cures in Shell-shock, Cases 

283, 310, 357, 365. 
Spirometer, 366. 
Staircase test, 190, 533, 640. 
Stansfield, 220. 
Statistics, 222, 227, 228, 362, 753, 784, 

812, 820, 831, 836, 839, 858, 864. 
Steiner, 704, 763, Cases 181, 182, 312, 

437. 
Stereotyped movements, 430. 
"Sterno" sign of Dupuoy, Case 161. 
Sterz, Case 123. 



Stewart, 741, 771. 

Stier, 222. 

Stomach, 400, 476, 479, 533, 701, 705, 
716, 807. Bib. 950, 951. 

Stokes, 268. 

Stovaine anesthesia, 778, 779. 

Stransky, 866. 

Stress, 226, 227, 867 (see also Exhaus- 
tion, Fatigue and passim). 

"Stupefaction" of muscle, 355, 542, 
890. 

Stupor, 362, 369, 435, 462, 486, 503. 
Bib. 933. 

Stupor, "local" (peripheral), 542. 

Stuttering, 681, 638, 817, Cases 219, 527, 
579, 586 (see also Speech disorder). 

Subconscious, Bib. 909. 

Suggestion (see also Auto-Heterosugges- 
tion), frontispiece, 95, 318, 338, 476, 
477, 438, 498, 653, 872. Bib. 910, 912, 
915, 931, 961. 

Suicide, 257, 258, 261, 283, 351, 460, 468, 
478. 

"Superposition" of hysterical symptoms, 
53i, 533, 545, Case 68. 

Supinator longus, 353, 355, 892. 

Surgery, 118, 158-161, Cases 66, 69, 146, 
252 (see also Treatment, Shell-shock 
neuroses, pseudo-operations) . Bib. 
954, 960, 962, 964. 

Sur 'simulation, 656. 

Sympathetic nerve effret, 394. 

Sympathy, 718, 719, 901 (see also "Poor 
dears!"). 

Sympathy with enemy, 245, 258, 319,851. 

Symptomatic psychoses (see Somato- 
psychoses) . 

Syncope, pleural, 187. 

Syndesmitis, 525. 

Synesthesialgia, 433. 

Syphilopsychoses, 836-839, 875, Cases 1- 
34. Bib. 934, 937, 941. 

Syphilis and epilepsy, 66, 67, Cases 45, 
55. 

Syphilis, in the army. Bib. 972, 974. 

Syphilis, danger of vaccination in, 85. 

Syphilis, in married women, 16. 

Syphilis, in munition-workers, 16, 838. 

Syphilophobia, 260. 

Syringomyelia, 570, 663. 



INDEX 



£ 



Tabes dorsalis, Cases 4, 20, 21, 22, 23. 

Bib. 930. 
Tachycardia, 76, 103, 198, 260, 309, 359, 

526, 529, 533, 641, 689. Bib. 907, 923. 
Tachypnoea, 526, 846, Case 137. 
Teeth, 701. 

Tension, arterial (see Blood pressure). 
Tetanos fruste, Case 120. 
Temperature changes in hysteria, 331. 
Tetanus, 845, 874, Cases 99, 119, 120, 

121, 280, 392, 403, 409, 419. Bib. 913, 

917, 919, 921, 927, 936, 946, 949, 952, 

954, 964, 966, 973- 
Thalamus, optic, 653, 876, Case 114. 
Theopaths, 851, Case 106. 
Thermanesthesia, Case 380. 
Thermo therapy, 607. 
Thibierge, 16, 30, 838. 
Thirst dreams, 475. 
Thorax, 94. 

Thyroid disease, Case 186. Bib. 912. 
Thyroid extract, 228. 
Tic, 282, 401, 428, 432, 446, 559, 577, 627, 

742. Bib. 917 951. 
Tinel, 356, 890, Cases 253, 315. 
Tobacco, 639. 
Todd, 804, Case 7. 
Tombleson, 846, Cases 142, 545, 546, 

547. 
Torpillage (see Treatment, Shell-shock 

neuroses, psychoelectric), 786, 895. 

Bib. 930, 964. 
Torpor, 487. 

Torticollis, 697. Bib. 951. 
Toxic psychosis (see Somatopsychoses), 

Bib. 914. 
Trauma and general paresis, Cases 15, 

18, 20. 
Trauma and neurosyphilis (also see 

Trauma and general paresis), Cases 5, 

16, 17, 19, 20, 24, 25, 27. 
Trauma, spinal, Cases 375-381. 
Traumatic neurosis, 347, 359, 749. Bib. 

915, 929, 930, 931, 935, 937, 946, 948, 

949, 952, 954, 956, 957, 958, 962, 967, 

97o, 97i, 972, 976, 977, 981, 982. 
Traumatic psychoses (see also Encephalo- 

psychoses), 490, 534, 872, 873. Bib. 

940, 968. 
Traumatropism, see Localization. 



Treatment, physiopathic or reflex dis- 
order, 671, 743, 787, 892, Cases 277-279. 

Treatment, psychoses, Bib. 918. 

Treatment, shell-shock neuroses; drugs, 
675, 677, 689, 777- 

Treatment, Shell-shock neuroses, Hydro- 
therapy, 588, 680, Case 484. Bib. 
962, 963, 973, 978. 

Treatment, Shell-shock neuroses, Hypno- 
tism, 347, 367, 499, 515, 532, 676, 681 
(in writing), 682, 697, 514, especially 
Cases 521-548. Bib. 970, 975. 

Treatment: Shell-shock neuroses by in- 
duced fatigue, 789, Cases 489-493. 

Treatment, Shell-shock neuroses, Isola- 
tion, 575, 672, 695, 708, 812, 820, 901. 
Bib. 929, 930, 937, 942, 966, 967, 969. 

Treatment, Shell-shock neuroses, Lumbar 
puncture, 693, 778, 779. 

Treatment, Shell-shock neuroses, Mech- 
anotherapy, 318, 560, 566, 691, 692, 
697, 698, 717, 718, 788, 821, 827. Bib. 
913, 940, 941, 960, 961, 964, 967, 971. 

Treatment, Shell-shock neuroses: rapid 
versus slow methods, 683, 695, 749, 
751, 782-797 (rapid or miracle cures), 
791, 872, 895. Bib. 965. 

Treatment, Shell-shock neuroses, Nar- 
cosis, 318, 332, 532, 676, 682 (alcohol), 
683 (alcohol), 737, 768 (alcohol), es- 
pecially Cases 552-559, but passim; 
560, 561 (stovaine). 

Treatment, Shell-shock neuroses, Occu- 
pation therapy, see passim, 683, 685, 
711, 803, 859, 893. Bib. 938, 979. 

Treatment, Shell-shock neuroses, Pseu- 
dooperations, 344, 264, 267, 588, 609, 
646, 821 especially Cases 514-521; 560 
and 561 (stovaine); 562 (X-ray). 

Treatment, Shell-shock neuroses, Psycho- 
electric, 696, 815, 827, especially 897 
and 898, Cases 230, 235, 250, 264, 401, 
404, 418 (628), 478, 513, 514, 555, 559, 
especially 563-574, 584. Bib. 929, 
930, 932, 942, 943, 948, 967, 976. 

Treatment, Shell-shock neuroses: faith, 
rationalization, explanation, persuasion, 
"tracing back", reassurance, etc., 463, 
474, 580, 622, 695, 701, 706, 707, 820, 
900, 901. Bib. 937, 967, 969. 



20 



INDEX 



Treatment, Shell-shock neuroses, Reedu- 
cation, 568, 683, 692, 735, 899, 900, 
901, Cases 230, 284, 293, 299, 387, 400, 
404, 447, 514, 550, especially 575-589, 
578 {respiratory). Bib. 913. 

Treatment, Shell-shock neuroses, Re- 
covery without medical treatment, 
Cases 283, 310, 357, 364, 365, espe- 
cially 473-477, 520. 

Treatment, Shell-shock neuroses, pre- 
arranged emotional shock (see Emo- 
tion), 680. 

Treatment, Shell-shock neuroses, relation 
to the front line, 675, 897. 

Treatment, Shell-shock neuroses, studied 
neglect, 672, Cases 67, 533. 

Treatment, Shell-shock neuroses, Psycho- 
therapy undefined, 553, 554, 874, 899 
(honeymoon type). Bib. 923, 926, 
950, 966. 

Tremophobia, 465, Case 308. 

Tremor, 282, 466, 492, 551, 622, 742, 
Cases 224, 308, 325, 327, 337, 483, 
502, 532, 535. Bib. 909, 945, 950, 

Tremors, head, 292, 708. 
Trench-foot, 718, 760, Case 132. 
Trephining (see also Organic neurology), 

490. 
Triad of Dieulafoy, 373, 609. 
Triplegia, 773. 
Trismus, 300, 771. 
Trophic changes, 603. 
Tubby, 354, Cases 254, 285. 
Tuberculosis, 239. 
Turner, 718, 804, 901. 
Turrell, Cases 121, 568. 
Tympanum, 300. 
Typhoid fever, Cases 123, 124, 135, 276. 

Bib. 229. 
Typhus (and war psychoses). Bib. 928, 

955, 960, 970, 972. 

Ulnar syndrome, Case 136. 
Urology, Urine, 347, 377, 427, 476, 527, 
533, especially 535-6, 805. 

Vago-accessorius nucleus, 265, 884. 
Vagus, 701. 



Vasomotors, labile, 260, 387, 428, 569, 

639, 742 (also passim). Bib. 921 (arte- 
rial hypertension). 
Veale, Cases 511, 512. 
Venereal diseases (see Syphilis, Urology, 

etc.). Bib. 920. 
Verger, Case 61. 
Vertigo, Case 105. 
Vestibular symptoms, Cases 31, 368, 398, 

439, 515. 
Vicissitudes of treatment, 796 and 

passim. 
Victoria cross, 741, 891. 
Vigouroux, 44. 
Vignolo-Nutati, 429. 
Vincent, 266, 696, 723, 753, 820, 894, 900, 

Cases 277, 278, 566, 564. 
Vincent's treatment (see Treatment, 

Shell-shock neuroses, psychoelectric). 
Violence, 75, 76, 252-255. 
Vision (see also Ophthalmology), 490. 

Bib. 931, 934, 974. 
Visual fields, contracted, 253, 254, 374, 

551. Bib. 936. 
Vlasto, Case 519. 
Vocational reeducation, 803. Bib. 915, 

916, 917, 924, 926, 930, 940, 971, 973, 

974, 975, 978. 
Voltaic vertigo, 621, 624. 
Vomiting (see Stomach). 
Von Sarbo, 348, Case 410. 
Voss, Cases 455, 457, 569. 
Vulpian, 608. 

Wagner v. Jauregg, 348. 

Walshe, 828. 

Walther, Case 404. 

War and Neurology, Bib. 915, 922, 928, 

934, 938, 946, 950, 95i, 952, 953, 954, 
956, 957, 967, 968, 971, 973, 974, 977, 
981. 

War Neurosis (see Shell-shock, Hysteria, 
etc.). 

War and Psychiatry (see also Recruits, 
Hospital Organization), Bib. 920, 921, 
922, 925, 926, 928, 930, 931, 932, 933, 

935, 938, 940, 943, 944, 946, 953, 954, 
956, 960, 962, 963, 965, 969, 971, 973, 
974, 977, 979, 980, 981. 

War stress, 226, 227, 289. 



INDEX 



(tl 



Wassermann reaction in suspected Shell- 
shock, 12. Bib. 927. 

Wassermann reaction in epileptiform 
seizures, 65. 

Weichardt, 689. 

Wernicke, 161, 409. 

Westphal, 348, Case 435. 

Westphal and Hubner, Cases 73, 290. 

Weygandt, 863, Cases 3, 160, 165, 416. 

White hair (see canities). 

Will therapy, 322. 

Wilmanns, 228. 

Wilson, Gordon, 812. 

Wiltshire, 404, 519, 675, Cases 216, 324, 
325, 337, 338, 345, 357. 

Windage, 185, 275, 276, 289, 317, 378, 
S5o. 

Wish-fulfillment, 361. 

Wollenberg, 348, 447. 

Women, Syphilis in, 16 (see Civilians). 

Wound shock, Bib. 909, 927, 961. 

Wounds (brain), 914, 917, 918, 923, 924, 
926, 929, 931, 932, 934, 935, 943, 946, 
947, 95°, 953, 958, 959, 968, 977, 980. 



Wounds (skull, head), 914, 915, 916, 917, 
918, 920, 922, 923, 924, 925, 926, 932, 

934, 935, 936, 939, 94i, 943, 944, 945, 
946, 949, 953, 954, 960, 962, 964, 965, 
967, 968, 969, 970, 971, 972, 974, 975, 
977, 978, 980, 981. 
Wright, H. P., 589. 

Xanthochromia, spinal fluid, 282. 

X-Ray, 354, 480, 529, 531, 534, 559, 561, 
565, 566, 594, 596, 602, especially 606- 
608; 648, 725, 789, 798. Bib. 913. 

Yealland, 723, 753, 786, 900. 
Yealland's treatment (see Treatment, 

Shell-shock neuroses, Psychoelectric). 
Yes-no test, 651, 770. 

Zange, 815. 

Zanger, Cases 294, 482. 

Zeehandelaar, 348, 674, 790. 

Zoopsia, 164. 

Zum Busch, 228. 



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